Vina Moses Donation Form

What Inspired you to make a donation today?

____Our Newsletter
____Our Website
____Gazette Times
____Word of Mouth
____Church Group

____Our Benefit Sale
____Honorarium/ Special Event
____Other Organization
____Other_______________

I am making a gift of:

_____$20 _____$30 _____ $45_____ $75 _____ $100 _____ $ 150 _____$200

or $_________ (Please indicate amount)
Designate your gift? (optional) ___________________
Options include: FISH, School Program, Holiday Program, Family Visits, Discretionary Fund (where it's needed most) or
Endowment Fund

Please fill in your name and address completely to ensure proper preparation of your receipt.

Name

Address

City

Telephone Number (optional)

Email Address (optional)

____________________________________________

____________________________________________

______________ State _____ Zip Code ____________

____________________________________________

____________________________________________

Please make your check payable to "Vina Moses Center" --or -- Fill in the following to charge
your donation to your credit card. Visa and Mastercard are accepted.

Account # ____________________________________ Exp. Date ___________________

Name (as it appears on your credit card) _________________________________________

Signature ____________________________________ Date ________________________

This form should be sent to: Vina Moses Center, 968 NW Garfield St., Corvallis, OR, 97330.
Thank you for your Gift!! Your generosity will ensure the continued success of the Vina Moses Center.
All donations are tax-deductible.