South Cove Community Health Center: Donation print-out

Fill out and print this form to enclose with your donation.

I would like to donate to South Cove Community Health Center:

My check of $ is enclosed.
I would like to make a pledge of $ over years.
Please charge my Visa or Mastercard for $ .

Card # Expiration date
Signature ___________________________

I would like to discuss other donation options with you. Please contact me as soon as possible:

Name

Address

City State Zip

Telephone Fax

E-mail

Print and mail this form to:

South Cove Community Health Center
Attn: Division of Development
145 South Street, 4/F
Boston, MA 02111
(617) 521-6715 TEL
(617) 521-6799 FAX

I would like to donate to South Cove Community Health Center:
	My check of $ is enclosed. I would like to make a pledge of $ over years. Please charge my Visa or Mastercard for $ .
		Card # Expiration date Signature ___________________________

I would like to discuss other donation options with you. Please contact me as soon as possible:
	Name
	Address
	City	State Zip
	Telephone	Fax
	E-mail