Lone Star Chapter of the National Hemophilia Foundation
Donation/Gift Acknowledgement Form

If this gift is in memory or in honor of someone and you would like to inform a third party of your gift, please provide the following information:

Donation amount

Donation made in honor of

Donation made in memory of

Who would you like us to notify of your gift (include person's name and full address, phone number optional?

Would you like us to know anything special about this individual?

Please give us your information
(used only for the purpose of this acknowledgement)

Company
(if corporate gift)

Name

Address

City State      Zip

Day Phone Evening Phone

Cell Phone Fax

Email Address

Would you like your name printed in our newsletter? Yes          No

Would you like to be added to our mailing list? Yes          No