Fax to: MAGNUM Inc.
At: (703) 739-2432

Complete fully:

First Name:______________________________

Last Name:______________________________

Street Address:_________________________________________________

City:___________________________________

State:________________________

Zip:_________________

Credit Card Information:

Check One:

[   ] Visa [   ] MasterCard [   ] American Express [   ] Discover

Complete fully:

Credit Card Number:____________________________

Cardholder Name:______________________________

Expiration Date:______________

Signature:_____________________________________


Donation Options:

Choose One:

[   ] Check here if you want our Migraine Patient Information Kit sent to you by priority mail.
The amount of $10.00 will be billed to the card above.

[   ] Check here if you want our Migraine Patient Information Kit sent to you but would also like to make an additional donation. The cost to have the Patient Information Kit sent to you by priority mail is $10.00. Please fill in the amount of the additional donation below.

Migraine Patient Information Kit: $10.00

Amount of Additional Donation:______________

Amount of Total Donation:__________________

[   ] Check here if you already have a Migraine Patient Information Kit or don't need one.

[   ] Check here if you specifically do not wish to recieve any migraine information and are just sending in a donation.

Amount of Total Donation:__________________


Optional for donars of more than $50.00:

[   ] In the Sponsors section of this site, MAGNUM will list as recognition of contributions made to this 501(c)(3) non-profit organization, the names those who contribute $50.00 or more. If you do not wish your name to be listed among MAGNUM benefactors and remain anonymous, then check here.

Optional Personal Information:

Choose one:

[   ] Check here if you are a Migraine sufferer. [   ] Check here if you are getting information for a friend or loved one.

If you do suffer from Migraines, how often do you suffer acute Migraines?
Choose One:

[   ] Less than 3 times a month. [   ] 3-8 times a month. [   ] 9 or more a month. [   ] Essentially Daily.