TEX HYPAC 2011-2012
PLEDGE CAMPAIGN
YES! I COMMIT TO DONATE ONE HOURS PAY EACH MONTH TO HELP PASS LEGISLATION TO FURTHER THE PROFESSION OF DENTAL HYGIENE IN TEXAS!
| NAME: | COMPONENT: | 07 | |||||
| ADDRESS: | CITY,STATE,ZIP: | ||||||
| PHONE: | EMAIL: | ||||||
| AMOUNT:$ | |||||||
| FREQUENCY: | monthly (Oct 11-Sept 12) | □ | one time | □ | |||
| METHOD OF PAYMENT: |
CHECK |
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| MC/VISA #exp____/____ | |||||||
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SORRY, NO DISCOVER/AM EX |
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SIGNATURE (REQ:) |
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| Please defer my annual pledge until Feb. 2012 - Feb. 2013 Yes or NO | |||||||
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