MY ANNUAL THANK YOU FOR YOUR HELP

Enclosed with this card is my tax-deductible donation to:
Irondequoit Ambulance Services, Inc.

I would like to contribute:    $100 $75 $50 $25 Other $__________

Name:____________________________________________

                  Your Receipt
Date:     ___________                          Your donation in any                                                                          amount is greatly appreciated

Amount:___________  Agent signature__________

Cut here along dotted line



Please print this form and mail to:
Irondequoit Ambulance
2330 Norton Street
Rochester, NY 14609