DEADLINE: For inclusion in the Auction Catalog, please have all donations in by October 1, 2013

1. DEADLINE: For inclusion in the Auction Catalog, please have all donations in by October 1, 2013 Item#: __________________ AUCTION DONATION FORM DONOR INFORMATION Company/Family Name (as it should appear in publication) I do wish to appear in publication I do not wish to appear in publication Contact Name: (please print) Address: City: State: Zip: Email: Phone: AUCTION ITEM ITEM: Estimated Value: Description of ITEM (as it should appear in publication) Is there an expiration on the item or service? No Yes Date Please list all restrictions, blackout periods and limitations Delivery or pick-up arrangements: Mail to FCSN c/o 20472 Crescent Bay Drive #102, Lake Forest, CA 92630 Please pick up item (we will arrange a time with you) Certificate enclosed Certificate will be mailed to above Lake Forest, CA address Please make a gift certificate from the description above Other form of arrangement Solicitor’s Name: I do not have an item to contribute, however, I wish to make a tax-deductible cash contribution of $ . PLEASE MAKE YOUR CHECK PAYABLE TO FIREFIGHTER CANCER SUPPORT NETWORK. YOU WILL RECEIVE A WRITTEN ACKNOWLEDGEMENT. **ALL CASH DONATIONS SHOULD BE MAILED TO ** FIREFIGHTER CANCER SUPPORT NETWORK 2600 West Olive Ave., 5th Floor – PMB 608 Burbank, CA 91515 Tax ID # 20-4192265 Please email or fax completed Auction Donation Form to: Fax (949) 900-2021 Email: donations@fcsngalaauction.com Questions: (800) 351-5596