Donation Form
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1
2Donation Form - Print, Fill Out, and Mail
Print this donation form, fill it out (please print legibly), then mail to the following address
along with a check or money order.
Fund Development Office
Our Hospice of South Central Indiana, Inc.
2626 E 17
Street
th
Columbus, IN 47201-5417
DONOR INFORMATION:
Individual or Organization
First Name: _________________________________
Middle Name: ________________________________
Last Name: ____________________________________
Organization Name:______________________________
Spouse/Partner’s Full Name: __________________________________________
Address 1: __________________________________________________
Address 2: __________________________________________________
City: _________________________________________
State/Province: _________________
Zip: ___________________
Country: _____________________
Phone: (___)__________________________
Email address: _______________________________
GIFT INFORMATION
Amount:___________________
Gift designated for:
•
Our Hospice of South Central Indiana Inc.
•
Our Hospice of Decatur / Shelby
•
Our Hospice of Jennings County
•
Our Hospice Inpatient Facility
•
Wings for the Journey
•
Where Most Needed
This gift is in memory of: ______________________________________________
This gift is in honor of: ________________________________________________
For the occasion of:
____________________________________________________________
(Examples: anniversaries, birthdays, weddings, retirements, Father’s or Mother’s Day,
Christmas, etc.)
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