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Donor Form
First Name                       Last Name

Address

City State Zip


Phone Email

Gift Information:

I would like to support UMEC with a gift of:
$25.00 $250.00 I would like to volunteer my time
$50.00 $1,000.00
$50.00 Other $

Payment Information:

Card Type:
Card Number:
Card Security Code:
Expiration Date: /

Gift designation:

Greatest Need     Linn Health Care Center Improvements
Corporate Matching Fund     Affordable Assisted Living Fund
Chaplaincy Fund     Other Fund

Tribute Information:

Please send notification to:
Name

Address

City State Zip