To make a donation to the Jackson Hospital Foundation Inc., a 501(C)3 nonprofit organization, please provide the following information:
Amount of Donation: | _________________________________
|
Your Name:
Address:
City, ST Zip:
Phone: | _________________________________
_________________________________
_________________________________
_________________________________
|
Is this gift unrestricted? | Yes: _____ No: _____ |
If no, this gift is restricted
or designated for: |
_________________________________ |
Is this donation in honor
or memory of someone? |
In honor _____ In memory _____ |
If so, whom? | _________________________________ |
If so, where would you like the notification letter sent? |
Name:
Address:
City, ST Zip: | _________________________________
_________________________________
_________________________________ |
| Your credit card information: |  | | | |
Card Type: | Visa / MasterCard / Discover / American Express
(Circle One) |
Card Number:
Expiration Date: | _________________________________
_________________________________ |
Name that appears
on the card: |
_________________________________ |
Signature:
Date: | _________________________________
_________________________________ |
|
Please mail or fax this form to:
Jackson Hospital Foundation
PO Box 1608
Marianna, FL 32447
Fax Number 850-482-6374 |
|