Complete and mail or fax to: Bread and Water for Africa®
2550 Huntington Avenue, Suite 200, Alexandria, VA 22303
FAX: 703-317-9690
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Donation Information

Donation Amount: $ ___________________
Please check that your name and address are correct to ensure proper preparation of your receipt .
Name: __________________________________________ Company/Organization:___________________________
Street Address: __________________________________
City: ______________________   State: ______________
Zip: ________ Country: _______ Phone: (          )            -    
Email Address: _______________________________

Check or Credit Card Information

□ I have enclosed a check made payable to Bread and Water for Africa®.
□ I wish to use a credit card. (please complete the information below and mail/fax this form to the address listed at the top of this page.)
Name on card:_______________________________________
Card Type: □ Visa      □ MC      □ AMEX      □ Discover
Account #: __________________________________
Expiration Date: _____________
Signature: _________________________  Date: _________

Comments: 

Thanks for                  
your support!