Please print this form, complete it, and mail it to:
The Texas Heart Institute
Development Office, MC 3-117
PO Box 20345
Houston, TX 77225-0345

If you have questions, please call 832-355-3792.
Thank you for advancing the struggle against cardiovascular disease.

The enclosed tax-deductible gift in the amount of $_____________________
is to be applied to the fund checked:

         ___Research    ___Education    ___Greatest Need    ___Endowment

My check is enclosed, payable to the Texas Heart Institute, or charge my gift to:

     ___Visa      ___American Express    ___MasterCard      ___Discover

Name of cardholder:________________________________________________

Account no.: _________________________________ exp. date: ____________

Signature:_________________________________________________________

Donation from (Name):_____________________________________________

Address:_________________________________________________________

City:______________________________State:________Zip:_______________

Phone:__________________________ Fax: ____________________________

E-mail: __________________________________________________________

This gift is: _____ in memory of      _____ in honor of

Name: ___________________________________________________________

Please notify (Name):_______________________________________________

Address:_________________________________________________________

City:___________________________________State:_______ Zip:__________

Notes:___________________________________________________________

_________________________________________________________________