Donation Form I/we would like to make a donation to the Eagles Heart and Cancer Telethon or Prairie du Chien, Wi.. The Eagles Heart and Cancer Telethon is a 501(c)3 non profit organization.

5$1,000 5$500 5$250 5$100 5$50 5$25

Other$______________________

_______________________________________________________________________________ Name(s)_________________________________________________________________________ Address_________________________________________________________________________ City______________________________________ State__________________ Zip____________ Telephone___________________________Email ________________________________________ This gift is made in 5honor of

5memory of

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_________________________________________________________________________________ Special Instructions________________________________________________________________ _________________________________________________________________________________ __________________________________________________________________________________ _________________________________________________________________________________ Signature______________________________ Date_________________________ --------------------------------------------------------Payment Information-----------------------------------5My check is enclosed, made payable to Eagles Heart and Cancer Telethon Send to: 200 S. Beaumont Rd Prairie du Chien, WI 53821 Mark envelope: Donation