Making Donations to

The North Central District AIDS Coalition

Print form to fill out and send along with your payment.

Name:     _________________________________________________________________________________

Address:  _________________________________________________________________________________

City:        _________________________________________________________________________________

State:       _________________________________________  Zip Code: _______________________________

Daytime Phone: ____________________________________________________________________________

Evening Phone:  ____________________________________________________________________________

E-mail:             ____________________________________________________________________________

Gift Amount:   ____________________________________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Check Enclosed

Cash Enclosed

Is This a Memorial Gift or Tribute Gift?

I am making this gift:   in memory of  in honor of

Name:       ______________________________________________________________

Occasion:  ______________________________________________________________

Mail to:  North Central District AIDS Coalition              P.O. Box 658              Lock Haven, PA  17745

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