General Donation Form - Alzheimer's Association



2257425-812165General Donation Form00General Donation FormGeneral Donations for the Capital of Texas ChapterDonor information (person making the donation)*Receipt will be sent here. If receipt address is different than the billing address, please note and provide both addresses.*First Name ____________________________Last Name ___________________________Address: __________________________________________________________________City:_________________________________ State:_______________ Zip:_____________Phone number;_________________________ Email Address ________________________Billings Address (if different than address above):Address: __________________________________________________________________City:_________________________________ State:_______________ Zip:_____________Donation informationI would like to make a donation in the amount of: __$200 __$100 __$50 $______Other (Please list amount)____ I have enclosed my credit card donation____ Enclosed is my check payable to the Alzheimer’s Association ____ Enclosed is my cash donationPlease charge my _____Visa ______MasterCard ______Discover ______American ExpressCredit card number: _____________________________________Expiration date: ___________________ CVV code:___________________Signature: __________________________________________ Today’s date: _____________________If you wish to make your gift in memory of honor of a loved one or friend, please fill in the information below. An acknowledgement of your gift will be sent to the person named to inform him/her of your thoughtfulness. Your gift amount will not be mentioned.This gift is made ___ In honor of:___ In memory of:Name ___________________________________________________Please notify:_________________________________________________________Name_________________________________________________________Address_________________________________________________________City, State, and Zip CodeReturn completed form to:Capital of Texas5508 West Hwy 290, Ste 206Austin, TX, 78735 ................
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