Jean Hardisty Legacy Fund Donation Form

Name: ________________________________________

Address: ______________________________________

_____________________________________________


I want to honor Jean with a contribution to the
Jean Hardisty Legacy Fund.

   Enclosed is my donation of :
[_] $1,000       [_] $500       [_] $250
[_] $100 [_] $50 [_] Other _____

Please make checks payable to Political Research Associates
(note "Jean Hardisty Legacy Fund on the memo section of the check)
and mail this form along with your donation/pledge to:
   Political Research Associates
   1310 Broadway, Suite 201
   Somerville, MA 02144-1731.