Please print this form and mail it with your contribution to:

Valley Lutheran Scholarship Organization
5199 N. 7th Avenue
Phoenix, Arizona 85013

Name (Please Print):_________________________________________

Address:___________________________________________________

City:_______________________________________________________

State:______________________________________________________

Zip: _______________________________________________________

Phone: ____________________________________________________

Social Security Number: ______________________________________

Donation Amount: ___________________________________________

Check Number: _____________________________________________

Date of Check: ______________________________________________

Please check one:
____ Married filing jointly - up to $1000
____ All others - up to $500

Apply my donation to:
____ Valley Lutheran High School
____ Martin Luther School

Checks should be made payable to:
Valley Lutheran Scholarship Organization

Rev. January 5, 2006