Draw Down Order Form

Support the ICA Marathon Team
Print this form then fill in and mail with your donation to:
Support ICA Marathon Team, ICA, 548 S. Ruby Lane, Fairview Heights, IL 62208

If using a credit card, you can fax your order to 618-394-9869

PLEASE DO NOT EMAIL.
THIS IS NOT A SECURED SITE. MAIL OR CALL ICA AT 618-398-7500

Please fill out this form, print, sign and mail to the address at the top.

Thank you for supporting Illinois Center for Autism.

If you would like your donation designated on behalf of a specific member of the Relay Team,
Enter the Team Members name:

___________________________________________________________________

Name            _____________________________________________________________

Address        _____________________________________________________________

City               ______________________________________ State ____    Zipcode ___________

Phone          _________________

Donation Amount    ________________

Method of Payment:         ___   Check        or        __    Credit Card

                                                                      __ Visa
                                                                      __ Master Card

                                                                      Card # _ _ _ _   _ _ _ _   _ _ _ _   _ _ _ _

                                                                       Exp. Date _ _ /_ _

Signature _______________________________________________________