Donation Form

Foundation Donation Form _____ I would like to make a gift In the amount of: ________________________________________________________ In Honor / Memory of: (circle one) ________________________________________________________ ________________________________________________________ Please send acknowledgement of my gift to: Name: ________________________________________________________ Address: ________________________________________________________ City/State/Zip: ________________________________________________________ Your credit card information: Card Type: ________________________________________________________ Card Number: ________________________________________________________ Name that appears on the card: ________________________________ Expiration Date: ___________ Signature: ______________________________________ Date: _____________

Please mail or fax this form to:

Lincoln County Health System Foundation
106 Medical Center Boulevard
P. O. Box 1458
Fayetteville, TN 37334

Phone: (931) 438-7471
Fax: (931) 438-7456

"Giving to Life . . . and a Lifetime of Giving."