You may print this contribution form and submit it off-line in any 
of the following ways:

Snail Mail:  The Special Needs Network
             103 Schelter Road
             Lincolnshire, IL  60069

Phone:       847-522-8080 
Fax:         847-522-8081


Enter the amount you wish to donate

$___________ 


Personal Information

This is the address to which your receipt will be sent, and also the
address to which items will be shipped unless otherwise specified below.
                 
Name           _______________________________________________________

Address        _______________________________________________________

City           _________________________ State __ Zip ________________

Phone          _______________________________________________________

E-Mail Address _______________________________________________________



Payment Information

Select your credit card type:

__Visa
__Master Card
__Check Enclosed


Name as it appears on card ___________________________________________

Credit Card Number         ____________________

Expiration Date (mm/yy)    __________