Print and Complete this form and mail with payment (check or money order) made payable to:

The Microtution Foundation
926A Diablo Avenue, # 111
Novato, CA 94947

THE MICROTUTION FOUNDATION SPONSOR AND MEMBERSHIP FORM

First Name___________________________   Last Name_____________________________________

Address_____________________________________________

 City_________________________

State______ Zip ________ 

Email________________________________________

Evening Phone_(_____)_______________ 

Day Phone_(_____)___________________

Contact me to Volunteer!!   YES_______  NO________

   I WANT TO GIVE 

$25___    $50___    $100___  $250___ $500___  $1000___ Other____                                                                                 Sponsor   Member    Activist   Statesmen of the Microtution Foundation

Statesmen Members:  Opt-in publishing of your name, city, state:  YES_____     NO______

At this time your contribution is not tax deductible.  The Foundation has filed for 501c(3) status and our counsel believes contributions to the Foundation will become charitable in the coming months.