As a direct result of your past generosity, during 2004, North Carolina Physicians Health Program awarded a record-breaking $13,500 in treatment scholarships, allowing nine physicians/physician assistants to enter into long-term treatment programs. As anyone in recovery would concede, this is a vital ingredient for getting into successful recovery and staying there! Please help NCPHP and its participants by replenishing our treatment scholarship fund. No amount is too small - and the cause couldn't be more important. Your contribution can salvage a colleague's career, save lives, and ensure quality health care for millions of North Carolina's citizens. No small feat!

Payment by check enclosed $______________.
Please charge my credit card the sum of $_______________.
I would like to make a pledge as follows:
Charge my credit card at monthly intervals beginning on (date) _____/______/_____ in the amount of $_________ per month for __________ months.
Credit card information: VISA MasterCard
Account # _____________________________________________
Exp. Date ___________

Signature: _____________________________________________________________________

Please print name: ______________________________________________________________
Billing Address: _________________________________________________________________
City, State, Zip: __________________________________________________________________

Please mail completed form with your check to:

NCPHP
220 Horizon Dr
Suite 218
Raleigh, NC 27615

You may fax this completed form with credit card information to (919) 870-4484 if you prefer. You will be provided a receipt for your tax-deductible donation.

FINANCIAL INFORMATION ABOUT THIS ORGANIZATION AND A COPY OF ITS LICENSE ARE AVAILABLE FROM THE STATE SOLICITATION LICENSING SECTION AT 1-888-830-4989. THE LICENSE IS NOT AN ENDORSEMENT BY THE STATE.