The 11^th Annual Mike Pollom Memorial Charity Golf Tournament

Monday, April 16, 2012 

DONATION FORM

 1. Checks payable to the Desert Community Foundation, memo:                       

 The Mike Pollom Scholarship Fund

2.  Donor Name:_______________________

     Address:_______________________________________________

    ______________________________________________________

     Phone:_______________________Email:_______________________

 3.  Credit Card Charge:     Amount:  $_______________

       Card Type:___________Card #:_________________________    (Master Card/Visa only)

        Expiration Date:_______ Security Code:_______

       Name on Card:__________________Signature:_________________________

 Donations 100% tax ID #95-4725924

Send this completed form and payment to:

Mrs. Karen Myers, Financial Chairwoman

115 Don Quixote Drive

Rancho Mirage, CA 92270