Karen Spelman Memorial Scholarship Fund

Please circle the amount you wish to donate or specify an amount in "other". 
$1000   $500  $250  $100  $50
Other (specify amount) _____________________ 


Full Name:  ____________________
E-Mail Address: ____________________  

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We should expect your payment by (Please check):
Phone___ Fax___  Mail___  Credit Card___
 

MasterCard/Visa Card Number:  ___________________________ 
American Express Card Number:  ___________________________
Expiration Date:  _________________
You must specify a complete street address so that we can acknowledge your donation.
 Street Address:  ___________________________
City:  ___________________________
State/Province:  ___________________________
Postal/Zip Code:  ___________________________  
Country:  ___________________________
[+Country Code] Phone:   ___________________________


Please mail this form and make checks or money orders payable to:
The Option Institute
ATTN: Karen Spelman Memorial Scholarship Fund
2080 S. Undermountain Road
Sheffield, MA 01257-9643


(Outside of the US: We can only accept International Money Orders in US currency drawn on a bank with a US office.)

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Thank you very much,
Karen Spelman Memorial Foundation Scholarship Fund