CONTRIBUTION FORM
Name: _______________________________________________________________
Address: _____________________________________________________________
City: ___________________________________________ State: ____ ZIP: ______
Phone: (____) _____ - __________
Amount:
q $100 q $250 q $500 q $1,000 q $2,500 q $5,000 q Other (Specify) __________
Frequency:
q One-time gift q Annual (number of years _____ ) q Monthly (number of months ____)
Payment method:
q Cash q Check q Automatic Debit to Bank Account (contact us for form)
Credit Card: q Visa q MasterCard q Discover
Card Number: ____________________ Exp. Date: ___/___/___
Signature: ____________________________________________________________
Return this form to:
Madison County Community Health Centers, Inc.
Attn: CFO
P.O. Box 349
Anderson, IN 46015
Receipt: detach at dotted line
Name: __________________________________________ Date: _______________
Amount of this Gift: $_______________ Total Amount Pledged: $_____________