Online Donation (Items marked with an * are required.) |
I would like my gift to go to: |
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Personal Information |
* First Name: |
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* Middle Inital: |
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* Last Name: |
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Spouse Name: |
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* Home Phone Number: |
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Work Phone Number: |
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* Mailing Address: |
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* City: |
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* State: |
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* Zip Code: |
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Email Address: |
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Contact |
Please contact me about making a planned gift to the
St. Alexius Foundation.
Anonymous Gift
Grateful Patient and Families Program
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This donation is being made in honor of: |
(birthday, anniversary, event) |
This donation is being made in memory of: |
(deceased person) |
Indicate the name and address of the person you wish to be notified of this honor/memorial gift: |
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Credit Card Information |
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Above Info the Same – Check This Box |
* Payor’s Last Name: |
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* First Name: |
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Middle Initial: |
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* Mailing Address: |
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* City |
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* State: |
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* Zip Code: |
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* Phone Number: |
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* Credit Card Type Accepted: |
MasterCard
Visa
DiscoverCard |
* Credit Card Number |
(xxxxxxxxxxxxxxxx) |
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* Security Code On Credit Card: |
(xxx) |
* I/We Donate the following Amount: |
$
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Comments: |
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