06/21/96

Everett P. Blizard Scholarship

E-mail Contact:

1. Contribution Amount to Everett P. Blizard Scholarship :

2. Method of payment

Check: American Express: MasterCard: VISA:

3. Contributor's Name:

Card Number:

Expiration Date:

Signature:

4. Name and address

5. Send To:

American Nuclear Society
Attn: Christian Knapp
P.O. Box 97781
Chicago, Il 60678-7781