Please X one of the following:

[  ]  Name of the bike rider you will sponsor

      ____________________________

[  ]  I wish all of the bike riders well and my donation covers all of them

I want to aid sarcoma research and will make a donation to the Liddy Shriver Sarcoma Initiative.

Please X one of the following:

[  ]  $100

[  ]  $250

[  ]  $500

[  ]  $1000

[  ]  or, the amount of $___________

My Name:

Make your check out to "FJC".  The memo line should say "Liddy Shriver Sarcoma Initiative". Send your check with this form to:

Liddy Shriver Sarcoma Initiative

17 Bethea Drive

Ossining, NY 10562-1620

or directly to FJC at:

FJC

520 Eight Avenue, 20th Floor

New York, NY 10018

As a 501(c)(3) non-profit, charitable organization, contributions to the Liddy Shriver Sarcoma Initiative are tax-deductible for US citizens. FJC will send you an acknowledgement of your contribution for tax purposes.

My Address:

My Phone:

My E-Mail Address:

How did you learn of this event?