Donation Form ...(for pick up)

 

Company donations 

              Personal donations  

 

Name__________________________________________________________________________________ 


Address _______________________________________________________________________________ 


City ___________________________________ State ___________________Country __________________


Post Code (Zip) ___________________________________


 
Phone ___________________ fax #___________________

 

Quantity

Donation/description

 

Item # (if any)

Total cost (approx)

 

 

 

 

$

 

 

 

 

$

 

 

 

 

$

 

 

 

 

$

 

 

 

 

$

 

 

 

 

$

 

 

 

 

$

 

 

 

 

$

 

 

 

 

$

 

 

 

 

$

 

 

 

 

$

Instructions:                                            

Total:

$

 

 

Total: 

PLEASE CHECK APPROPRIATE BOXES t o make  monetary donations

 

 

( ) MasterCard............. ( ) VISA............. ( ) American Express                 TOTAL:$

 

TOTAL:$ 

Name on card: __(Print)__________________________________________________________________

 

Card No. # ____________________________________Exp.Date :___________

Signature ____________________________________ Date _______________

Pick up /Delivery date & time:  

 

Contact Tel.#