Make a Contribution ... Make a Difference! 		InterAgency Council of Glen Cove, Ltd
PO Box 532
Glen Cove, NY 11542
(516) 759-7380
info@iacglencove.org
www.IACglencove.org
Our member agencies rely on the generous contributions of supporters just like you. Your generous donation to the InterAgency Council is used to Help Us Help others by supporting the wide range of community services and activities ... and we thank you! Your contributions are tax deductable to the full extent permitted by law. Please print this form to make donations by mail to the above address. 
Date	: ____________________________

SUPPORTER INFORMATION

Name    : ____________________________________________________

Company : ____________________________________________________

Address1: ____________________________________________________

Address2: ____________________________________________________

City/State/Zip : _____________________________________________

Phone # : ____________________________________________________

eMail   : ____________________________________________________


DONATION INFORMATION

Donation Amount $ ______________________

Please let us know how you would like to apply your donation.

 To the InterAgency Council of Glen Cove as a whole.
 For these InterAgency Council Member agencies/services:

______________________________________________________________

______________________________________________________________


PAYMENT INFORMATION

Please make IAC donations payable to the 
Glen Cove Youth Board
and mail to the above address. 

Enclosed is  Check   Money Order


Signature ____________________________________________________