| Please print and send this form to: COMPASSION IN DYING of Oregon 6312 SW Capitol Hwy, Suite 410 Portland, OR 97201 |
 |
| Please print and send this form to: COMPASSION IN DYING of Oregon 6312 SW Capitol Hwy, Suite 410 Portland, OR 97201 |
|
I would like to become a contributing member of COMPASSION IN DYING of Oregon. Name _________________________________________________________________ Address: _______________________________________________________________ City: _______________________________ State: _____________ Zip: ____________ Day Phone: __________________________ Evening Phone: _____________________ My pledge of $250, $100, $50, $25 or $_________ will be paid: – Monthly – Quarterly – Semi-annually Payable by: – Enclosed Check – Visa – Master Card Credit Card #_________________________ Expiration date: _____________________ Name of cardholder: _____________________________________________________ Signature: ______________________________________________________________ – This contribution is in memory of __________________________________________ – This contribution is a gift to _______________________________________________ Please notify _____________________________________________________________ Address: ________________________________________________________________ City ________________________________ State ___________ Zip: _______________ COMPASSION IN DYING of Oregon is a 501(c)(3) nonprofit
organization. Thank you for your support. |