Print out this form and mail to the address below:

Name:	___________________________________
Address:	___________________________________
City, State, Zip:	___________________________________
Telephone:	___________________________________
Email:	___________________________________

My company will match this gift. (If possible please attach form)

Company Name: ___________________________________

Sponsors will receive regular newsletters by mail or e-mail. Check your choice below:

Send my newsletter
via postal mail
via e-mail
No newsletter please

Your Donation

I/we would like to sponsor the Eber family’s ride around the world for asthma (15,000 kilometers) at _________ per mile (fill in amount: e.g. 1?, 10?)

Check one below:

I am paying the full amount of __________ now.

Please bill my charge card according to the installment plan. I understand that my card will be billed immediately for _________ (10% of the full amount; see payment calculator). I authorize World Bike for Breath to bill the remaining amount in 18 monthly installments of ___________ (5% of the full amount; see payment calculator) beginning January 2003 and ending June 2004. I may withdraw from the First Sponsors Club at any time by canceling this agreement.

Method of payment:
Circle one: Visa Master Card Personal check (for full amount of donation only)

Credit card number: _______________________________________

Expiration date: _________________________________

MAIL TO: