USTRS Contribution Form

The Dr. John Barry Traveling Fellowship Award in Transplantation Contribution Form

Urologic Society for Transplantation and Renal Surgery

Thank you for making a tax-deductible contribution to the USTRS Dr. John Barry Traveling Fellowship Award in Transplantation.

All Benefactors are gratefully acknowledged in the meeting program and website - unless you indicate otherwise. Thank you!

First Name *

Middle

Last Name *

Organization / Company

Address *

City *

State/Province/Region *

Zip/Postal Code *

Country

Email Address: (for confirmation) *

Acknowledgment listing okay? *

Yes

The most frequently given amounts are shown below but you can choose any amount you wish in the next box.

Contribution - $250	Contribution - $50	Contribution - $75
Contribution - $100	Contribution - $500

Contribution (custom)

Optional: In dedication to or in memorial of
(please state which and give full name):

General Comments:

Click "Continue" button below. On the next page you may pay your fees by check or by credit /debit card using the PayPal checkout cart.

Note: All Funds go to the Urologic Society for Transplantation and Renal Surgery (USTRS) Dr. John Barry Award Fund. The USTRS is a 501 (c) (3) tax exempt charitable organization. Contributions are deductible under section 170 of the IRS Code. TIN 46-3864810 (Click here for W-9 form)