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Donor Information:
 

Name ____________________________________________

Address __________________________________________

City, State, Zip ____________________________________

Phone __________________ E-mail ________________________


_____In Memory of___________________________________________

      Send acknowledgement card to:________________________      

          Relationship to deceased:___________________________________

          Address:____________________________________________

          City, State, Zip______________________________________

_____In honor of _______________________________________

                   Occasion_____________________________

                    Address_____________________________

                    City, State, Zip

Donation Information:
____   Check in the amount of $ _________________ enclosed
____   Credit Card in the amount of $ ____________________

Credit Card Type:  ___________________________________________
      (VISA, MasterCard, or American Express)

Credit Card No.: ______________________________________________

Expiration Date: ____  /  ______

Name as it appears on card: ___________________________________

____   Gift Of Securities

Security: ___________________________________________

Number of Shares: ______________________________________________


(We will contact you to arrange for transfer of securities.)

Mail to:

American Red Cross
Colonial Virginia Chapter
1317 Jamestown Road #105
Williamsburg, VA. 23185

If you are using your credit card, you may fax this form to (757) 253-2396.
Thank you for your donation to the Colonial Virginia Chapter of the American Red Cross.