Vaisnava Name (if applicable)_________________________________________________________________
 

Street:_______________________________________________

Apartment #:__________

City:_________________    State__________________________

Zip Code:_____________  Country_________________________

---

 

□ Credit Card #:

Visa:_______________________   Exp. Date:__________

Master Card:_____________________  Exp. Date:________

 

□ Personal Check        □ Money Order       □ Cashiers Check     

□ Other (please specify)

---

 

□ Regular Donation                   □ Memorial Donation

If sending an In-Kind or Memorial gift please fill out the following on the person in who's name the donation will be made.

Name:___________________________________ Title:__________

Address:_______________________________________________

             _______________________________________________

            ________________________________________________

Would you like the amount of donation to be stated in the Thank-you letter?  

□ Yes     □ No

Optional personal message to be included with the Thank-you letter:

Your message here:

Amount of Donation:

__$11  __$21  __$51  __$108  __$1,008

or other amount

$___________________Place numeric dollar amount here

_________________________________________________________Please write amount in words here.

 

Thank You for Your Kind Donation

You will receive a receipt for your tax records within 7-10 business days