Check Donation

Please complete and print this form and mail it with your check to:

North Sunflower Medical Foundation
P.O. Box 369
Ruleville, MS 38771

Items marked with an asterisk (*) are required.

Last name*

First name*

Address 1*

Address 2

City*

State*

Zip*

Day phone

(please include area code)

Home phone

The best way to reach me is by: Email US Mail Telephone

Amount of check enclosed $

This gift is in

honor of
memory of

If you wish this person to be notified of your gift (amount
of gift will not be indicated), please supply their address:

Is this your first gift to the Medical Foundation? yes no

How would you like your name listed in publications?

I wish this gift to be credited anonymously.

I wish this gift to be credited jointly with my spouse.

Spouses Name

Please contact me about

Making a planned gift
Including the Medical Foundation in my will
Making a gift of securities
Making a gift of real estate
Setting up a charitable remainder trust

Comments

Please print this page and mail it with payment to:
North Sunflower Medical Foundation
P.O. Box 369
Ruleville, MS 38771