African-American Insurance
Professionals Association

13TH ANNUAL SCHOLARSHIP DINNER
SILENT AUCTION DONATION

Name _____________________________________________________

Company/Organization _______________________________________

Address ___________________________________________

City  __________________________     State  _________       Zip Code _________

Donation _____________________________________________________

Telephone  ______________     Fax _______________  

 

			Print this form and send with your donation to: 

Raydella Lewis
c/o Keenan and Associates
2355 Crenshaw Blvd., Suite 200
Torrance, CA 90501
 501(c)(3) Federal Tax ID #01-0820726