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Delta Health Foundation, Inc. Donation Form
Here is my gift of:
____$25 ____$50 ____$100 ____$500 ____$1,000 ____Other $_________
Donor’s Name_______________________________________________________
Address_______________________________________________________
City ________________________________________
State_______________ Zip _____________
Phone (_____)__________________________
E-mail____________________________________
Charge my credit card: _____ MasterCard _____ Visa _____ American Express
Is this a company credit card? _____ yes _____ no
If yes, company name_________________________________________________________
Name as shown Card_________________________________________________________
Card number_________________________________________
Exp. date____________________
Signature
_____________________________________________________________
If paying by check, please make your check payable to Delta Health Foundation, Inc.
Please fill out this form and mail, with donation, to:
Delta Health Foundation, Inc.
7401 Delta Lane
Charlotte, NC 28215
Delta Health Foundation is a 501(C)(3) charitable organization. Contributions to Delta Health Foundation are tax deductible to the full extent allowed by law. To control expenses, the Foundation will send receipts for gifts of $25.00 or more.
___My employer has a matching gift program; please send me information on how to double my gift.
___I’m interested in automatic monthly, quarterly or semi-annual giving; please send me more information.
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