Preservation Fund Donation Form

Please print and mail this page.
Please credit the fund with my tax-deductible contribution of:

$ 10. $ 25. $ 50. $100.

$ 200. $ 500. $1000. Other $______

Contributions of any amount are gratefully accepted.

Please acknowledge my donation but not the amount.

I wish to remain anonymous.

Please acknowledge by donation as a tribute to:

_____________________________________________

 

Name: _______________________________________

Address: _____________________________________

___________________________________________

E-mail: ______________________________________

Phone: ______________________________________

 

Method of Payment

Check (payable to Lakewood Historical Society Preservation Fund)

Bill me

Visa

MasterCard

__________________________________   _______________
Credit Card #                                                                                    Exp. date

__________________________________________________
Signature