Tribute Gift Form

Please complete this form and either fax to 314-534-5001 or mail to:

Dance St. Louis

3547 Olive Street, Suite 301

St. Louis, MO   63103-1014

Call 314.289.4109 with any questions.

Enclosed is my gift of $___________________

• In honor of: _______________________________________________________

From: ____________________________________________________________

• In memory of: _____________________________________________________

From: ____________________________________________________________

• I would prefer to remain Anonymous in all publications and listings.

Please send acknowledgement to:

Name:   _________________________________________________________________

Address:     _______________________________________________________________

City/State/Zip:     __________________________________________________________

Please send receipt to:

Name:     _________________________________________________________________

Address:    _______________________________________________________________

City/State/Zip:   ___________________________________________________________

• Enclosed is my check made payable to Dance St. Louis.

• Please charge my gift:

__ MasterCard                         __Visa              __ Discover

Card Number: ___________________________   Expiration Date: __________________

Name on Card: ___________________________________________________________