We Have Supported
the Medicine Box^® Program

Name of Church or Group:_______________________________________

Address:_______________________________________________________

Name of Contact Person:________________________________________

Phone:_________________________________________________________

An Advance Special Check in the amount of $375 was sent on:____

The "Kit" was sent to I.M.A. on:________________________

   You may prefer to use our graphic version (30K), a reproduction of the form in the printed packet.