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 Please print, fill out, and mail in with your donation, to the address below. Thank you. I would like to make a contribution to Gilead Community Services in the amount of: ____ $500 ____$100 ___$50 ____$35 _____Other |
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| First Name: ____________________ | Last Name:________________________________________ | ||
| Address Line 1: ________________________________________________________________ | |||
| Address Line 2: ________________________________________________________________ | |||
| City:____________________________ | State/Province:__________________________ | Zip:_____________ | |
| Country:____________________________________________________ | |||
| Email Address:____________________________________________________ | |||
| Daytime Telephone Number:____________________________________________________ | |||
| Company (if applicable):____________________________________________________ | |||
| Card Type: ____ Mastercard ____ Visa | |||
| Card Number:____________________________________________________ | |||
| 3 Digit Security Code:_________________________________________________ | |||
| Expiration Date: (month/year) | |||
| Cardholder Name: ________________________________________________________ | |||
| ___ I have enclosed a check made payable to Gilead Community Services | |||
| You may either FAX this form to: (860) 344-3339 | |||
Or, MAIL this form with your check to:
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