Please print this form and mail to: Charlevoix Area Hospital Foundation, 14700 Lakeshore Drive, Charlevoix, MI 49720, or fax to: 231-547-8658.

Your information:
Title: Miss Ms. Mrs. Mr. Dr.
Other
Name:
Address:

City, State, Zip Code:
Country:
Phone (include area code):
Fax (include area code):
Email Address:

I wish to receive future email correspondence.

I prefer to make my donations anonymously.

Gift amount & type:
Amount: $
Pledge Gifts: Gifts of $1,000 or more may be made in installments over one to three years.

The above amount is a Pledge Gift to be paid in the following manner:

$ annually $ quarterly
$ other (please detail)

Please remind me of this commitment:
Monthly Quarterly Annually


Gift designation (choose one):
To the department or area within the hospital
To community health education and outreach programs
Other (please specify):
Undesignated
In Honor of (optional):
In honor of:
Please send acknowledgement to:
Address:

City, State, Zip Code:
In Memory of (optional):
In memory of:
Please send acknowledgement to:
Name:
Address:

City, State, Zip Code:


Credit card information (we accept all major credit cards):
Card Type: MC Visa Am.Ex. Other
Credit Card #:
Expiration Date:

Fill in below only if different from the information above.
Name as it appears on Card:
Billing address for Card:

City, State, Zip:
Billing phone # for card: