Before
starting this donation form, please scroll through it completely to see
what information is required. If you leave the form before submitting
it, all the information you have entered will be lost. If you prefer,
you may print this form and mail it to the address listed below. (Note:
a * represents required
information).
Donor
Information
*My name
My spouse's name
My company's name
A corporate contact is
*
My home address
*
City
* State
*
Zip
My business address
City
State
Zip
*
My daytime telephone
My evening telephone
My e-mail address
Please contact me
about including Western Reserve Health Foundation in my estate plans
and tax saving charitable gift opportunities.
Payment
Information
*
Gift amount
*
Please charge my
*
Card Number
* Expiration date
For MEMORIAL or SPECIAL OCCASION gifts
please complete the following:
In memory of (name)
In honor of (name)
Occasion
For other special requests or directed
donations, please contact Western Reserve Health Foundation at
330.884.4772
Please
send an acknowledgement to:
(The
amount of the gift will be kept confidential.)
Name
Address
City
State
Zip
Check your information
for accuracy,
then click "Submit"
If mailing this application instead of submitting it electronically,
please send it to the following address:
Western Reserve Health Foundation
PO Box 240
Youngstown, OH 44501
Contributions
to Western Reserve Health Foundation are tax deductible to the extent
allowed under IRS guidelines. You will receive a receipt via U.S. Mail.
For more information, please call us at 330.884.5858.
