_________________________________
   

Your Name:
Address:
City, ST Zip:
Phone:

_________________________________
_________________________________
_________________________________
_________________________________
   

   
Is this donation in honor
or memory of someone?

   
   
In honor _____   In memory _____

Name:
Address:
City, ST Zip:

_________________________________
_________________________________
_________________________________

Visa / MasterCard / Discover / American Express
(Circle One)

Card Number:
Expiration Date:

_________________________________
_________________________________

Name that appears
on the card:

   
_________________________________

Signature:
Date:

_________________________________
_________________________________

   
Send check, money order or this form with your credit card information to:
Amery Regional Medical Center Foundation
265 Griffin Street East
Amery, Wisconsin 54001
Fax (715) 268-0205
Phone: (715) 268-8000