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For inclusion in the Auction Catalog, please have all donations in by

October 1, 2013

Item#: __________________

AUCTION DONATION FORM

DONOR INFORMATION

Company/Family Name (as it should appear in publication) Address: I do wish to appear in publication I do not wish to appear in publication Contact Name: (please print) City: Email: State: Phone:

AUCTION ITEM

ITEM: Description of ITEM (as it should appear in publication)

Zip: Estimated Value: Is there an expiration on the item or service?

Please list all restrictions, blackout periods and limitations No Yes Date Delivery or pick-up arrangements: Mail to FCSN c/o 20472 Crescent Bay Drive #102, Lake Forest, CA 92630 Please pick up item (we will arrange a time with you) Certificate enclosed Certificate will be mailed to above Lake Forest, CA address Please make a gift certificate from the description above Other form of arrangement Solicitor’s Name:

I do not have an item to contribute, however, I wish to make a tax-deductible cash contribution of $

PLEASE MAKE YOUR CHECK PAYABLE TO FIREFIGHTER CANCER SUPPORT NETWORK. YOU WILL RECEIVE A WRITTEN ACKNOWLEDGEMENT.

**ALL CASH DONATIONS SHOULD BE MAILED TO **

FIREFIGHTER CANCER SUPPORT NETWORK 2600 West Olive Ave., 5 th Floor – PMB 608 Burbank, CA 91515 Tax ID # 20-4192265

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Please email or fax completed Auction Donation Form to: Fax (949) 900-2021 Email: [email protected]

Questions: (800) 351-5596