Yes! I want to make a difference in the fight against breast cancer in Siouxland!  
Please accept my donation of:

_____  $100 Patron (Special Pink Ribbon gift for Patron members)

_____  $50 Bronze

_____  $20 

_____  Other ($________)

Please make checks payable to Susan G. Komen for the Cure. The Komen Foundation is a non-profit 501(c)(3) organization.

Name:_________________________________________
Address:_______________________________________
City, State, Zip:__________________________________
Phone:_________________________________________
Email Address:___________________________________

_______ I am a breast cancer survivor

Please mail donations to:
Susan G. Komen for the Cure
Siouxland Affiliate
P.O. Box 1116
Sioux City, IA 51102-1116