Please print this form and mail it with your donation to:

AmericanDestiny, Inc.
9 Music Square South
Suite 202
Nashville, TN 37203
(615)895-1919


CONTACT INFORMATION
COMPANY:             ____________________________________________

NAME:                ____________________________________________

ADDRESS:             ____________________________________________

                     ____________________________________________
		 
CITY, STATE, ZIP:    ____________________________________________

PHONE:               ____________________________________________

FAX:                 ____________________________________________

EMAIL:               ____________________________________________


BILLING INFORMATION
COMPANY:             ____________________________________________

NAME:                ____________________________________________
               
ADDRESS:             ____________________________________________

                     ____________________________________________
		 
CITY, STATE, ZIP:    ____________________________________________


DONATION INFORMATION
AMOUNT:  ___ $35 ___ $50 ___ $100 ___ $250 ___ $500 ___ $1,000 ___ Other:  ___________

PAY BY:  ___ Check ___ Credit Card
     
C.C. Type: ____________________________ C.C. Number: _________________________________
		 
Expiration Date: ______________________ Authorization Code: __________________________
		 
Name on Card: _________________________ Signature: ___________________________________