Your Information

Name     ____________________________________________

Address ____________________________________________

                ____________________________________________

City         __________________________  State _____   Zip __________

Telephone _______________________   Email  _______________________________

School/College/Club Affiliation -  __________________________________________

Your Contribution

Directed towards -  

__ Unrestricted
__ National Team Training Center
__ Mercer Junior Rowing Club
__ Rebecca "Little Becca" Annitto Memorial Fund
__ Upcoming Regattas (please see website for more information
__ Other (Please specify) __________________________________

Amount  $_____________          Check enclosed  ___  or  Credit Card charge  ___

            Master Card ___, Visa ___, AmEx ___, other ____________

            Credit Card # ___________________________________

            Name on card  _______________________________________

            Expiration Date ___________    Signed _________________________________