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Ctbhi Gift Form

Ctbhi Gift Form

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Published by CTBHI
Form to contribute to the CT Breast Health Initiative in New Britain, CT
Form to contribute to the CT Breast Health Initiative in New Britain, CT

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Categories:Types, Research
Published by: CTBHI on May 05, 2013
Copyright:Attribution Non-commercial

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05/14/2014

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CT BREAST HEALTH INITIATIVE, INC.

GIFT/PLEDGE FORM


PERSONAL INFORMATION:

Name:
______________________________________________________________________________________
(check applicable box) Survivor Spouse of Survivor Family of Survivor Friend of Survivor Other

Home Address: _______________________________________ Phone: __________________________


City: ____________________________________________________ State: _________ Zip: __________


Email Address: ________________________________________________________________________


Name(s) if gift is being made by more than one person:

______________________________________________________________________________________


Gift in support of (name of individiual)________________________________________________________________________

Memorial Donation in honor of (name of individual)____________________________________________________ _________

Please send acknowledgement to name of individual(s):

_____________________________________________________________________________________________ ___________

Home Address: _________________________________________________________________________

City: ____________________________________________________ State: _________ Zip: ___________


METHODS OF PAYMENT:

Enclosed is my CHECK (made payable to CT BHI) for $_______________.______

Charge my CREDIT CARD $_______________.______

Name on Credit Card __________________________________

Card # __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ __ 3-digit security code_________

Visa MasterCard Discover - Expiration Date: __ __/ __ __


Signature: ___________________________________________________ (must be signed for Credit Card Transaction)


Please print, sign and mail or fax this form to:

CT Breast Health Initiative
185 Main St. Room 210
New Britain, CT 06051
Fax: 860.827.7105

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