MAKE A GIFT - Instructions:                                PRINT THIS PAGE

This is not an online form. Print this page out, complete the form, and mail this with your tax deductible donation to:

Foundation Office
Bon Secours Community Hospital
160 East Main Street
Port Jervis, NY  12771

Please accept my gift of: ( ) $_____ ( ) $100 ( ) $50 ( ) $35 ( ) $25 ( ) $15
Check made payable to Bon Secours Community Hospital
Title: (Mr / Mrs / Miss / Ms) ______

First Name:________________________________

Last Name:________________________________

Address:________________________________

Town:________________________________

State: _______Zip Code: _____

If contributing by credit card:
Credit Card Type: (circle) MC , Visa
Credit Card Number:

__ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

Expiration Date: Month ____ Year ____

Signature (required when donating by credit card)

_________________________________ Date: ____ / ____ / ____

I wish to make a gift ___ In honor of, or ___ in memory of:

Name: _______________________________ Occasion: _________________

Please send an acknowledgment card to:

Name:________________________________

Address:________________________________

Town:________________________________

State: ______ Zip Code: ___________

(The amount of the gift will not be mentioned unless you instruct us to.)

Please check this box ___ to receive further information on Wills, Trusts and Bequests

Please check this box ___ to receive further information on our Bon Secours Society.

Please check this box ___ if your employer / company has a Matching Gift program and enclose your matching gift form.