Washington DC Chapter of Concerned Black Men, Inc.

CONTRIBUTION FORM

Please send your tax-deductible contribution to:

                   Concerned Black Men, Inc., of Washington, D.C.

                   The Thurgood Marshall Center

                   1816 – 12th Street, NW. Suite 203

                   Washington, DC  20009-4422

Amount enclosed:

$25.00  ____        $50.00  ____           $75.00  _____    $100.00  _____

$250.00 ____     $500.00  ____   $1000.00  ____        Other  $_____

Name:          ­­­­­­­­­­­­­­­­­­_______________________________________

Address:      ­­­­­­­­­­­­­­­­­­_______________________________________

                   ­­­­­­­­­­­­­­­­­­_______________________________________

                   ­­­­­­­­­­­­­­­­­­_______________________________________

Telephone:­­­­­­­­­­­­­­­­­­   _______________________________________

Fax:             ­­­­­­­­­­­­­­­­­­_______________________________________

E-mail:         ­­­­­­­­­­­­_______________________________________

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    /    /              Please send me information about membership.

The Thurgood Marshall Center

1816 – 12^th Street, N.W. • Suite 203 • Washington, DC 20009-4422

Phone: 202-797-7444 • Fax: 202-797-7447

E-Mail: office@cbmdc.org • Internet: http://www.cbmdc.org

A United Black Fund Member Agency #8551

Combined Federal Campaign (CFC) # 99894

Concerned Black Men, Inc.® is recognized as a 501(c)(3) tax-exempt organization by the Internal Revenue Service