Friends in Action of the Eastern Panhandle Donation Form

Please print this form, complete it, and mail it with your check, payable to Friends in Action of the Eastern Panhandle, to:

Friends in Action of the Eastern Panhandle

PO Box 1720

Shepherdstown, WV 25443

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I am making a gift/pledge in the amount of (please check one):

___$50   ___$75  ___$100   ___$250   ___$500   ___(Other)

Name: ­­­­­­­­­­­­­­­­___________________________________________

Address: ­_________________________________________

City: ____________________________________________

State: ___________________________________________

Zip Code: _______________________________________

Phone: __________________________________________

E-mail: __________________________________________

In Memory/Honor of (you may make your gift in honor/memory of someone).

To do so, please complete the information below:

( ) In Honor     ( ) In Memory of

Address: ________________________________________________________________

CREDIT CARD INFORMATION:

(  ) Visa     (  ) MasterCard

Card Number: _________________________________

Expiration Date: ____ /____

CCV: ____

MATCHING GIFT PROGRAM
You can double or triple the size of your gift if you or your spouse is employed by a company with a matching gift program. These companies often match contributions of their retirees too. All you need to do is obtain this form, fill out your portion, and send it to us. We will take care of the rest.

(  ) Enclosed is my company’s matching gift form