DONATION FORM

Name: ________________________________________________

Address: _______________________________________________

________________________________________________

Telephone: _____________________________________________

Email: _________________________________________________

Program that you'd like to contribute to:

___ General Purposes / All programs

Programs in Vietnam :
___ Tue Tinh Duong Free Clinic
___ iCAN Dream (scholarship fund)
___ CPAP - Neonatal Care Program
___ ADAP - Children Trafficking Prevention
___ Bicycles for poor students
___ Relief Efforts

Programs in San Jose region:
___ Happy 5 (child development)
___ Relief Efforts

Comments and suggestions:
_____________________________________________________

Thank you for your donation.

Please make check payable to ICAN
Send your donation to:

ICAN
532 Valley Way
Milpitas, CA 95035

ICAN is a 501(c)3 non-profit organization. Contributions to ICAN are tax-deductible.