* = required information

Donation Amount $ ______________

First Name* _________________________________________________________

Last Name* _________________________________________________________

Street Address* ______________________________________________________

___________________________________________________________________

City* ______________________________________

State*______________ Zip Code*_______________

Phone Number _______________________________

E-mail ______________________________________

I prefer to make my donation by:

____ Check or Money Order (Payable to Tri-County (Peoria) Urban League)

____ Credit Card (please enter information below)


____ MasterCard ____ Visa

Credit Card Number ________________________________ Exp. Date _________

Signature ___________________________________________________________
Send your gift to:
Tri-County (Peoria) Urban League
317 S. MacArthur Highway
Peoria, IL  61605

Thank you for your tax deductible contribution!

All contributions are tax deductible to the extent allowed by law.