| Donation and Honor/Memorial form Please fill out and mail to: |
||
| Water In Africa Through Everyday Responsiveness | ||
| 212 Xanadu Road , #507 | ||
| Wisconsin Dells, WI 53965 | ||
| I have enclosed a donation in US $______________. | ||
| Please check one of the following: | ||
|
Enclosed is my check |
||
|
Please charge my credit card, my billing address is below: |
||
| Name:________________________________________ | ||
| Address: ______________________________________ | ||
| City: ______________________ State: __ Zip: _____ | ||
| Country: ___________________________ | ||
| Phone: _______________ Email: _________________ | ||
| Type of credit card: MasterCard Visa Amex | ||
| Credit card number: ___________________________ | ||
| Expiration Date: ______________________________ | ||
| Signature: ___________________________________ | ||
| My gift is in honor of: ___________________________ (Name) | ||
| My gift is in memory of: ___________________________ (Name) | ||
| Please notify the following person of my gift: | ||
| Name:________________________________________ | ||
| Address: ______________________________________ | ||
| City: ______________________ State: __ Zip: _____ | ||
| Country: ___________________________ | ||
| *** End of Form *** | ||