Fax-In • Mail-In Annual Campaign Form

Civista Health Foundation PO Box 1701, LaPlata, MD 20646
Fax: 301. 934.0384

Checks Are Payable to Civista Health Foundation.
Credit card information is not secure in an email.

Please print this page and complete the information. You may mail or fax but do not e-mail credit card information please.

2006 - 2007 ANNUAL CAMPAIGN

I wish to contribute to the Annual Campaign and receive recognition for my gift at the following level:

____Associate ($50-99)

____Fellow: ($250-499)

____Benefactor ($1000 or greater)

____Sponsor ($100-249)

____Patron: ($500-999)

____ My best gift: $__________

Name (as you want it to appear in a donor list):

__________________________________________

Address____________________________

City, State, Zip _____________________ _________________________________, _____ ___________

Telephone __________________________

____ Check

____ Mastercard ____ Visa Card   # _______ - ________ - ________ - ________ Exp. Date ________

Amount Enclosed: $ ________

Cardholder Signature: ________________________________

___ Please send me information about gifts of insurance, appreciated securities and bequests. ?

___ My company makes matching gifts.