Mail in Form
  * Please answer all questions in bold.
 
  Title:
  *First Name:     M.I.:     *Last Name:     Suffix:
   
 
  *Address:
  *City:    *State:    *Country:    *Zip code:
  Phone:      *Email:
   
        Please add my email to your mailing list:
   
        I would like to make a one-time contribution of:
            *Amount: $
   
        I would like to make a recurring monthly contribution of:
            *Amount: $25.00 $50.00 $75.00 $100.00 or $
   
        I would like to make a contribution of $ per month / quarter / year
   
 
   
 
  Please print this form, fill it and mail it with the payment to

The Administrator
Forum for Democratic Change Headquarters
Plot 9, Entebbe Rd, Najjanankumbi
P. O. Box 26928
Kampala, UGANDA