Please apply this donation to:

ALS-PLS Focus on Research Fund

PLS Worldwide Patient Registry

Donation Made by:

Name

Company

Address

City, State, Zip

Phone

Email

In Honor of: (Please notify the following individual of my gift)         

Occasion, Birthday, Anniversary

Name

Address

City, State, Zip

Pledge:

I/we wish to pledge $ to the ALS-PLS fund at Northwestern University Medical School.  The pledge will be paid in installments over a period of years, with the first installment to be paid on

Credit Card:
If you would like to make a donation, please call Karen Smith Beil in the Northwestern University Development office at (312) 503-4764

Check:    Please print this page and submit with check

  payable to: NUMS ALS-PLS  in the amount of

 $

Mail donation:  

Office of Medical Development

Northwestern University

Feinberg School of Medicine

Abbot Hall, Suite 1312

710 North Lake Shore Drive