First Name*

Middle Initial

Last Name*

Street Address*

Apt/Suite

City*

State*
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip*

Home Telephone

Work Telephone

Other Telephone

Email*

---

To become a regular Beacon, you may elect to make a one-time contribution of $1,000 or a contribution of $100 per year for ten years:

One-time contribution of $1,000$100 per year for 10 years

---

You may elect to become a higher level Beacon with pledges paid over a ten-year period ($500/year for Emerald Beacon, $1,000/year for Ruby Beacon, and $2,500/year for Diamond Beacon)

Emerald Beacon - $5,000Ruby Beacon - $10,000Diamond Beacon - $25,000

---

Thank you for your contribution to the Beacons Fund!!

Please click on "Make Contribution" below to complete your payment.  You will soon be receiving a confirmation from the Cosmopolitan Diabetes Foundation, Inc., acknowledging your generous contribution.