The Rotary Foundation

Rotary’s US$200 Million Challenge

Interact Club Contribution Form
**Please note this form is only to be used for contributions crediting an Interact club. This form may NOT be used for individual contributions.** Interact clubs that contribute to the US$200 Million Challenge will receive a certificate.

Interactor/Advisor/Rotarian completing this form:
Name: _________________________________ Email address: ___________________________ Phone number: ____________________

Contribution from the Interact Club of _______________________
Sponsoring Rotary club: ______________________________________ District ______ Address: _______________________________ City: ________________________ State/Prov.:________________________ Country: ___________________ Postal Code: _________________ Email address:______________________________ Phone number: ____________________

Amount of Contribution: US$100




Payment type: □ Check enclosed (payable to The Rotary Foundation) Check # ______________ Credit Card

□ Visa

□ MasterCard

□ American Express □ Discover □ JCB

Card number: _________________________________ Expiration Date: _______________________________ Name as it appears on card: ______________________

□ Wire/electronic Transfer
Name of Initiating Bank: ___________________ Date of transfer:_________________
Contribution designation: PolioPlus

Please see reverse.

NSW 2150 Australia Germany RDG Klosterstrasse 24-28 40211 Duesseldorf. Germany In countries with currency restrictions. When contributing via wire/electronic transfer.Please send your contribution to the appropriate address below: United States The Rotary Foundation 14280 Collections Center Drive Chicago. please contact your district Rotary Foundation chair or district governor for the address to send contributions. Thailand. 4400. Yongdunpo-go Seoul 150-733 Korea Southern South America Rotary International Florida 1. Sri Lanka. 4380. such as Bangladesh.O. Pakistan. . Chile. Level 2 100 George Street Parramatta.2 1005 Buenos Aires. 7030 See address for the United States Brazil Rotary International Rua Tagipuru 209 01156-000 Sao Paulo. Miwon Building 43 Yoido-dong. Colombia. Philippines. SP Brazil Europe and Africa Rotary International Witikonerstrasse 15 CH-8032 Zurich Switzerland Great Britain and Ireland Rotary International Kinwarton Road Alcester Warwickshire B49 6PB England South Asia Rotary International. Central Wing 124 Janpath New Delhi 110 001 India Japan Rotary International NS3 Building. please check with the appropriate international office for the correct bank instructions for your district or country. South Africa. Peru. Kita-ku Tokyo 115-0045 Japan Korea Rotary International Rm. P. ON M4Y 3A5 Canada Districts 3300-3490. CF Argentina Southwest Pacific and Philippines Rotary International McNamara Centre. Egypt. 7000. and Zimbabwe. 705. Thapar House 2nd Floor. 4060-4250.7020. IL 60693 USA Canada The Rotary Foundation (Canada) Lockbox B9322 P. 1F 2-51-3 Akabane. Box 9100 Postal Station F Toronto. Nicaragua. 4370.

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