New Britain EMS Donation Form

Name____________________________________________________

Address__________________________________________________

City_____________________________________________________

 Amount of Gift $_______________

 Type of gift:

 ___ in memoriam    ________________________________________________________
                                                                       Name of person

____ Annual Fund

____Other

Method of payment:

 
____Master Card  _____Visa      _____Check    (Please do not send cash through the mail)

 
Credit Card Number _________________________________ Exp Date _______________

 
Signature __________________________________________________________________