Please print out and complete this form or the PDF version and mail it to us with your gift:
ICBL
c/o HRW
1630 Connecticut Ave NW Ste 500
Washington DC 20009
USA
I would like to contribute to the important work of the ICBL and enclose my tax-deductible gift for the amount of:
___ US $ 200 ___ US $ 100 ___ US$ 50 Other:___
(Please make all cheques payable to the ICBL. For cheques in currencies other than US dollars, please note that we will pay bank charges so contributions to the equivalent of US$50 and over will be welcomed.)
Please complete the following information only if you are making a credit card donation:
Credit Card Type___________________________________
Credit Card Number_________________________________
Expiration Date____________________________________
Name on Card_______________________________________ Name_______________________________________________ Address____________________________________________ City_______________________________________________
State/Province and Zip/Postal Code___________________________________________________ Country____________________________________________ Phone______________________________________________ Email______________________________________________
__ I wish to subscribe to Campaign Updates by e-mail
__ I only wish to receive Action Alerts
More information about our mailinglist/newsletter visit www.icbl.org/news/newsletter