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 To mail your check or money order, just print this form, fill out the information, and mail to: Amnesty International USA, 5 Penn Plaza, 16th Floor, New York, NY 10001. If you have questions, please call us at 1-800- AMNESTY.
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| Donation Information |
| * Indicates a required field. |
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| Type Of Donation: |
| Join |
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| Renewal |
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| Student and Youth Membership |
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| Gift Membership |
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Notify recipient____Yes ____No |
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Occasion____________________ |
| Monthly Giving |
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| Memorial Gift |
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| Honorary Gift |
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| Additional Gift |
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| *Donation Amount: |
| $25 ____ |
| $50 ____ |
| $75 ____ |
| $100 ____ |
| $250 ____ |
| $500 ____ |
| Other $____ |
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| Your Name & Email |
| *Email: |
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| *Prefix: |
____________________ |
| *First Name: |
____________________ |
| Middle Name/Initial: |
____________________ |
| *Last Name: |
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| Suffix: |
____________________ |
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| Billing Address |
| *Address Line 1: |
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| Address Line 2: |
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| *City: |
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| * State/Province: |
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| *Zip/Postal Code: |
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| *Country: |
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| Phone Contact |
| Home Phone: |
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Check box if your current address is the same as your permanent address. |
| Mailing List Subscriptions |
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Online Action Center
Sign-Up to receive action alerts from Amnesty International USA's Online Action Center on urgent cases needing your immediate help. |
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Amnesty Online
Receive news, items of interest, and action alerts from Amnesty International USA. Amnesty Online is published every two weeks. |
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Please send me updates about upcoming Special Offers, Events and Membership Opportunities. |
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| Payment Information |
| *Card Type: |
____ Visa
____ MasterCard
____ American Express
____ Discover
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| *Card Number: |
____________________ |
*Expiration Date:
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| Permanent Address |
| *Email: |
____________________ |
| *Address Line 1: |
____________________ |
| Address Line 2: |
____________________ |
| *City: |
____________________ |
| * State/Province: |
____________________ |
| *Zip/Postal Code: |
____________________ |
| *Country: |
____________________ |
| Phone: |
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| School: |
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Graduation Date
(mm/yyyy e.g. 05/2005): |
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| Please complete the sections below if you are making a Gift or Honorary/Memorial donation. |
| Recipient Name & Email |
| Email: |
____________________ |
| *Prefix: |
____________________ |
| *First Name: |
____________________ |
| Middle Name/Initial: |
____________________ |
| *Last Name: |
____________________ |
| Suffix: |
____________________ |
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| Recipient Home Address |
| *Address Line 1: |
____________________ |
| Address Line 2: |
____________________ |
| *City: |
____________________ |
| *State/Province: |
____________________ |
| *Zip/Postal Code: |
____________________ |
| *Country: |
____________________ |
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| Recipient Phone Contact |
| Home Phone: |
____________________ |
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Print out this form and mail it to:
Amnesty International USA
5 Penn Plaza, 16th Floor
New York, NY 10001
or call 1-800-AMNESTY
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Thank you!
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