PLEDGE FORM

Last Name: ____________________________________

First Name: ____________________________________

Address: ______________________________________

City: __________________________________________

State: ____________________ Zip: _________________

Phone:______________________

Bring this form and donations to the walk or mail them to Buddy Walk, DSNWV  P.O Box 2107 Cross Lanes, WV 25356

Please make checks payable to: DSNWV

All contributions are tax deductible as allowed by law

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Thank you for your support! 

Total Collected:  $_________________

Please photocopy this form as needed