Memorial Program

The Foundation for the Scientific Study of Sexuality

Memorial Program

Your Name and Address:  _________________________________

                                   _________________________________

                                   _________________________________

Your telephone or email:  _________________________________

The name of the person you wish to honor: _______________________

The name and address for the person to whom to send the memorial document (if some of this information is not known to you, we will attempt to locate it for you)

__________________________________

__________________________________

__________________________________

_______ Contribution Amount (a minimum of $25 is requested to offset the basic costs and to provide FSSS with a small contribution)

Please mail this form and your check to:

Clive M. Davis, Ph.D.
FSSS Memorial Program
317 Scott Ave.
Syracuse, NY 13224