CHARITABLE GIFTS & DONATIONS Form

I am interested in donating a gift of: $ _____________________
Choose one:

_____ In memory of
_____ In honor of
         Name: _______________________________

From:

Name:
Address:
City:
State:
Zip Code:
Telephone: (         ) -
E-mail Address:

Please send an acknowledgement to the following:

Name:
Address:
City:
State:
Zip Code:
Telephone: (         ) -
E-mail Address: