Donation Form for the AIHA Guideline Foundation Operating Fund

The AIHA Guideline Foundation (AGF) is exempt from federal income taxation under Section 501(c)(3) of the Internal Revenue Code. Contributions to the AIHA Guideline Foundation may be tax-deductible, as provided by law.

Your donation will be a valuable contribution in helping the AIHA Guideline Foundation meet its goals to develop and publish exposure guidelines on an ongoing basis.

______I would like to make a donation/pledge to the AGF Operating Fund.

______I would like to make a donation/pledge to support the development of ERPGs.

Payment Methods _____ I would like to make a donation by check or credit card: Amount enclosed is $ ______Check # ______Credit Card # ______Exp. Date: ______

_____ My company has a matching funds program.

_____ I would like to set up a pledge of $ ______over a _____year period. _____ Annually The first payment of $ ______is enclosed. _____ Semi-annually The first payment of $ ______is enclosed. (Not to exceed 5 years)

Date: ______

Printed Name: ______

Signature: ______

Address: ______

______

Phone: ______

E-Mail:______

Return to: AIHA Guideline Foundation, 3141 Fairview Park Drive, Suite 777, Fairfax, VA 22042