Independence House Donation Form

* Print this form and Mail to: *

Independence House Inc.
160 Bassett Lane, Hyannis MA 02601

or fax credit card information to 508-778-0143

 

Company:   _______________________________________

Name:        _______________________________________

Mailing Address:  ___________________________________
                       ___________________________________

Phone: _______________

      (please check one)
___ Platinum Circle $1000 and above
___ Diamond Circle $500 - $999
___ Gold Circle $100 - $499
___ Pearl Circle $50 - $99
___ Silver Circle $_____

___ The forms for a corporate matching gift from my employer are enclosed.

Payment Method:
___ Personal Check          ___ Visa          ___ Mastercard

Card Number: _________________________________
Exp. Date:     __/__/____

Signature: _____________________________________

___ I/We can donate services (describe):  _________________________
             _____________________________________________________



___ I am interested in becoming a volunteer.