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†Delta Health Foundation, Inc. Donation Form


Here is my gift of:
____$25 ____$50 ____$100 ____$500 ____$1,000 ____Other $_________

Donorís 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.
___Iím interested in automatic monthly, quarterly or semi-annual giving; please send me more information.


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