LEGACY CIRCLE

enrollment

Date * +

Prefix

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

I/We have planned a gift to The Leukemia & Lymphoma Society (LLS) in a: *

Amount of Gift $

I/We make this gift

in honor of

in memory of

Please enter name of the person whom you make this gift in honor/memory of:

I/We grant permission to be listed in LLS publications so this gift can inspire others.

Yes

No

I/We would like to receive a Legacy Circle certificate and pin as a thank you for my/our gift. *

Yes

No

If you would like to restrict your gift, please contact us at Legacy@lls.org or 800-462-7831 for appropriate gift language.