WE MOVE - Donation Mail/Fax Form

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Fax or mail to WE MOVE

Donation mail/fax form

WE MOVE
5731 Mosholu Avenue
Bronx, NY 10471

Tel: 347-843-6132
Fax: 718-601-5112
Email: wemove@wemove.org
Web site: www.wemove.org

DONOR INFORMATION

Name:

Address:

City:

State/Province:

Country:

Zip Code:

Tel:

Fax:

E-mail:

Check here if you are including
a matching gift from your employer:

PAYMENT INFORMATION

Check enclosed

Charge to my credit card

Visa

Mastercard

Amount $______________

Name of cardholder
(exactly as printed on card):

Card number:

Expiration date:

Card Verification Value (3 digits on back of card):

Signature of cardholder:

OPTIONAL

I would like to make my donation in honor of:

Please send a notice to Name:

Address:

City:

State/Province:

Country:

Zip Code: