To make a tax-deductible donation to the documentary file Brainstorm,
please print and mail this completed form with your donation check to:

The Foundation for Responsible Television
2904 Floyd Drive, Suite C-1
Dallas, Texas 75204

Attn: Brainstorm Film Project

Dear Sirs:

Enclosed please find a check in the amount of $ made out to The Foundation for Responsible Television (the sponsoring 501(c) 3 organization) as a donation toward the documentary film project BrainStorm.

I have included the word BrainStorm in the memo section of the check as well. (Below is my name and address so that you can send me a confirmation letter of my tax-deductible contribution).

Name:

Address:

City: State:

Zip Code: Email Address:

NOTE: This donation is made in honor/memory of: