TPAA Foundation Contribution Form
Donation to TPAA Foundation
Please make check payable to TPAA Foundation
I would like to make the following contribution/contributions to:
( ) Medical Mission $________________________________________________
( ) Education & Research Funds $______________________________________
( ) Foundation Endowment Funds $_____________________________________
( ) ____________Medical School ______________________________________
( ) Foundation General Fund $_________________________________________
( ) Rural School Children Project $______________________________________
( ) Dr. Pipit Chiemmongkoltip Advanced Medical Education Fund $_____________
( ) Other $_________________________________________________________
Total $____________________________________________________________
Name: ____________________________________________________________
Address___________________________________________________________
Telephone: _________________________________________________________
Email:_____________________________________________________________
Donation is tax deductible under the law. Please consult your tax adviser.
Mail your contribution with this form to:
TPAAF 2020-2021
1350 Covington Ct
Crown Point, IN 46307-5244