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Printable Donation Form

Please print, fill in, and mail this form to the address at the bottom of the page.

Donate to Marillac Clinic!

$ ___________ Yes! I want to do my part to help my neighbors!

If in Memorial / Honorarium:

In honor of__________________________________________________________

In memory of________________________________________________________

_____Where needed most (an unrestricted gift allows the Clinic to use its resources in the most effective and responsive way) 

Name__________________________________________________________

Address_________________________________________________________

City / State / Zip___________________________________________________

Email_____________________________________Phone_________________

(Please make check payable to Marillac Clinic • 2333 N. 6th Street Grand Junction, CO 81501)

THANK FOR YOUR CONTINUED SUPPORT! 

If paying by Credit Card:     Visa ____    MC ____   Other _____________________________ 

_________________________________________         expires________________________

Credit card acct number _________________________________________ 

Signature

____________________________________________________________________________

***I’m interested in how my donation of $50 or more may qualify for the Colorado Enterprise Zone Tax Credit. _______(ck here and information will be sent to you)

 

Thank You.

 

Marillac Clinic Donor Relations Department

2333 N 6th Street

Grand Junction, CO 81501

 

Contact 970-298-2234 with any questions