Please print the form below
Make check payable to
SBF/University Medical Center
and mail with this form to
Development and Alumni Affairs,
University
Medical Center,
SUNY at Stony Brook, Stony Brook, NY l1794-5430
The enclosed Research Gift in the amount of $___________ is made in
| [ ] tribute | [ ] memory of | [ ] the fight against |
|
Please Notify: Name ______________________________________________ |
| Address______________________________________________ |
| Relationship to Honoree _________________________________
|
| Donor Name_________________________________________ |
| Address ____________________________________________ |
| Telephone __________________________ |
| University Department ________________________________
|