Queens Hatzolah - Donation Form

Amount

$ .

One Time Charge

Monthly Charge

Weekly Charge

Personal Information

Male	Female
Title
(First Name used for credit card processing)
First Name
Middle Name
(Last Name used for credit card processing)
Last Name
Company
Address 1
Address 2
City
State
Zip
Country
Phone		ext
Email

Payment Details

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Card Type:
Card Number:
Exp. Date:	Month Year

Donation Type: (optional)

Dinner Reservation General Donation In Honor Of In Memory Of

Title

First Name

Last Name

To request that we send ‘a gift has been made in the name of’ letter, please enter the mailing address below:

Title

First Name

Last Name

Street Address		Suite / Apartment #		City
State		Zip		Country

Additional Details:

Comments

Donation Receipt Options
Email Only Mail Only Email & Mail