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

P. O. Box 566
New Britain, CT 06050
Fax: 860.827.7105