Please print this form.

Drug Watch International is registered as a charitable organization [501(c)(3)]; contributions are tax deductible.  Enclosed please find my check for $______________________________.

o $25 - $100            Contributing	o Over $1,000          Sponsor
o $101 - $500          Friend	o Other
o $501 - $1,000       Benefactor

  This contribution is:

o in honor of ______________________________
   o in memory of ____________________________
   o occasion________________________________

Please complete the information below so that we may appropriately record and acknowledge your gift.  Thank you.

Please send acknowledgment to:

Name:

Address:

City/State/Zip

Country

Your Name:

Address:

City/State/Zip:

Country:

Telephone:

Fax:

E-mail:

Organization:

I would like to charge the above subscription and/or contribution to my VISA or Master Card Account: (circle one)
VISA/Master Card Card No.: ______________________________ Expiration Date:______
Signature: _____________________________________

Mail check or VISA information and completed form to:
Drug Watch International, P.O. Box 45218
Omaha, NE  68145  USA

In order to maintain its independence, Drug Watch International does not accept funding from any level of government.