The Barry Wint Memorial Fund

Established February 23, 2008 at the

Advancements in Medicine 2008 Conference

Pledge and Contribution Form   First Name (*Required) Last Name (*Required) Middle Initial Address (*Required) Address (line 2) / Post Office Canada Jamaica United Kingdom United States Other Country   City/Parish (*Required) ALBERTA ALASKA ALABAMA ARKANSAS ARIZONA BRITISH COLUMBIA CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA GEORGIA HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MANITOBA MARYLAND MAINE MICHIGAN MINNESOTA MISSOURI MISSISSIPPI MONTANA NEW BRUNSWICK NORTH CAROLINA NORTH DAKOTA NEBRASKA NEWFOUNDLAND NEW HAMPSHIRE NEW JERSEY NEW MEXICO NOVA SCOTIA NORTHWEST TERRITORIES NEVADA NEW YORK OHIO OKLAHOMA ONTARIO OREGON PENNSYLVANIA PRINCE EDWARD ISLAND QUEBEC RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA SASKATCHEWAN TENNESSEE TEXAS UTAH VIRGINIA VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING YUKON TERRITORY Armed Forces Americas Military Base AMERICAN SAMOA STATES OF MICRONESIA GUAM MARSHALL ISLANDS N MARIANA ISLANDS PUERTO RICO PALAU VIRGIN ISLANDS State (*Required - if US) Zip Code (*Required) E-Mail Address (*Required) Telephone Number (*Required) ( ) -    Medical Mission to Jamaica: Are you interested in Short-term Medical Missions opportunities in Jamaica? Yes No Are you a member of the Diaspora?  (*Required) Yes No   Fund Contribution: US Dollars Jamaican Dollars 25.00   1000.00 50.00   2500.00 100.00   5000.00 500.00   10000.00 1000.00   25000.00 Other   Other   If other, enter amount here:   (no dollar signs or commas, numbers only)   Donation schedule: Monthly   Quarterly   Annualy   One Time Thank you!       OSDJ, Copyright 2008 - 2009 All Rights Reserved.