Please print this form & send it with your donation
(Please Print)

Name/Company's Name: ______________________________________________

Address: ___________________________________________________________

City: ________________________________State: ______________Zip: ________

E-mail Address: ___________________________

• Yes, Please send a receipt to the address above for tax purposes

• No, Don't send a receipt

• Yes, Please include my name/company's name on Cooper's Supporters page (you may send your company's logo if you'd like it to appear on the page)

• No, I don't want my name/company's name to appear on Cooper's Supporters page

Cooper Somerville
321 Delphia Ave.
Brea, CA 92821

Please make checks payable to : Cooper Somerville