From: Subject: Donation Form Date: Wed, 22 Oct 2008 11:17:40 -0400 MIME-Version: 1.0 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.vnahealthathome.org/Donation_Form.htm X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3198 Donation = Form

 

To=20 donate by mail please complete this form and mail to:

 

VNA=20 Health at Home, Inc. 

27=20 Siemon Company Drive =20

Watertown, CT=20 06795

 

 

 

I/we would = like to=20 support VNA Health at Home with a tax-deductible donation of: =

 

=A3$500         =20 =A3$250        =20 =A3$100 =20         =A3$50         =20 =A3$25         =20 =A3Other=20 ______

 

Name:=20 = ___________________________________________________________________

          &nbs= p;      =20  (Please list as you wish your name(s) to appear in donor=20 listings)

 

Address:=20 = _________________________________________________________________<= /P>

 

Phone:=20 _________________________ Email:=20 ____________________________________

 

Please use = this gift=20 to fund:  =A3 Home=20 Care    =A3=20 Hospice    =A3 Where = Needed=20 Most

 

=A3 Enclosed = is my check=20 made payable to VNA Health at Home

 

=A3 Please = charge my=20 =A3=20 MasterCard   =A3 = VISA

 

Card No.:=20 ________________________________________ Expiration:=20 _______________

 

Signature=20 (required = for=20 charges): = __________________________________________________

 

=A3 I wish to = make this=20 gift: =A3 in memory = of /=20 =A3in honor = of:=20 _________________________

          &nbs= p;            = ;            =             &= nbsp;           &n= bsp;           &nb= sp;           &nbs= p;           =20     =20    (Please print name of honoree = clearly.)

=A3 Please = notify the=20 honoree / honoree=92s family of my gift.

     =20 (To=20 protect the privacy of all donors, amounts of individual gifts are = not=20 shared.)

     =20

     =20 Name(s): =20 __________________________________________________

    =20

   =20   Address: =20 __________________________________________________

 

=A3 I wish to = remain=20 anonymous. Please do not publish my name.=20       

 

=A3 Enclosed = is my=20 employer=92s matching gift form.