Mail-in Donation Form

Title (Mr., Mrs., etc.):  _____________________________________________

Name (First, MI, Last):  ___________________________________________

Address 1:  ____________________________________________________

Address 2:  ____________________________________________________

City:  ________________________________  State:  _____  Zip:  __________

Phone (Circle one: Home  /  Work): __________________________________

Email:  ________________________________________________________

Please check one of the following:

___  Enclosed is my check for $_________________

___  Please charge my gift of $__________________ to

(Circle one)  Visa  /  MasterCard  /  AmEx

Cardholder Name __________________________________

Card No. _________________________________________

Exp. Date _________________________________________

3- or 4- digit CVV Code  ______________________________

Cardholder's Zip Code ______________________________

For memorial/tribute gifts, please also complete the following (check one):

___  in honor of ___________________________________________

___  in memory of _________________________________________

___  in tribute to __________________________________________

Please send acknowledgement of memorial/tribute gift to:

Name: __________________________________________________

Address: ________________________________________________

City, State & Zip: ___________________________________________