SPONSOR FORM

YES! I would like to contribute to the "Leukemia & Lymphoma Society" and support you in your first marathon!

(Please circle the appropriate selection below.)

Please make check payable to: The Leukemia & Lymphoma Society and mail it back to me by March 1, 2001. If that isn't possible, we will gladly accept donations after that date!

• Name:_________________________________________________________________
  
• Address:_______________________________________________________________
  
• City, State, Zip:___________________________________________________________

If you would like to charge your contribution to your credit card, please complete:

• MC/VISA (circle one)#_________________________________________________
  
• Name on Card:______________________________________________________
  
• Expiration date:_____________________________________________________
  
• Signature:___________________________________________________________

Thank You!!

Elaine F. LaBarge

38 Moon street

Southbridge, MA 01550