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Your tax-deductible contribution ensures people living with cancer will find strength, comfort and inspiration through our free program. As a special tribute, your gift can be made in honor of a loved one. Please print the form below and mail or fax it to: Gilda's Club Westchester |
Donation Amount (US$)
| __ $25 | __ $50 | __ $100 | __ $250 | __ $500 | Other ________ |
Donor Information
| First Name | _____________________________________________________ |
| Middle Name | _____________________________________________________ |
| Last Name | _____________________________________________________ |
| Address | _____________________________________________________ |
| _____________________________________________________ | |
| City | _____________________________________________________ |
| State/Province | _____________________________________________________ |
| Zip/Postal Code | _____________________________________________________ |
| Country | _____________________________________________________ |
| Phone | _____________________________________________________ |
| E-mail Address | _____________________________________________________ |
| __ I would like to receive email updates. | |
Billing Information
| __ The billing information is the same as the contact information. | |
| Address | _____________________________________________________ |
| _____________________________________________________ | |
| City | _____________________________________________________ |
| State/Province | _____________________________________________________ |
| Zip/Postal Code | _____________________________________________________ |
| Country | _____________________________________________________ |
Payment Information
Card Type |
__ Visa |
__ Mastercard | __ Discover | __ American Express |
| Cardholder's Name | _____________________________________________________ |
| Credit Card Number | _____________________________________________________ |
| Exp. Mo. | _____________________________________________________ |
| Exp. Yr. | _____________________________________________________ |
| CSC (What's this?) | _____________________________________________________ |
Memorial/Tribute Information
| __ This gift is a memorial/tribute gift. | ||
| Name of Honoree/Tributee | _____________________________________________________ | |
| I'm Donating in | __ memory | __ tribute |
Acknowledgement
| __ Please send an acknowledgement. | |
| Recipient Name | _____________________________________________________ |
| Recipient Address | _____________________________________________________ |
| _____________________________________________________ | |
| Recipient City | _____________________________________________________ |
| Recipient State/Province | _____________________________________________________ |
| Zip/Postal Code | _____________________________________________________ |
| Recipient Country | _____________________________________________________ |
| Recipient E-mail Address | _____________________________________________________ |
Referral Source
| How did you hear about us? | __ Google/Other Search Engine | __ A Friend | __ Email | __ Direct Mail | __ None |
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