Date: ___________

Donor Name:_______________________________________________________

Address (1): _______________________________________________________

Address (2): _______________________________________________________

City: _________________________ State:_______________ Zip: ___________

Gift Amount: $ ______________________ Check Enclosed: ____yes ____no

In Memory of: ______________________________________________________

VISA or MASTERCARD Number: _____________________________________

Credit card expiration date: _______________

Signature: ___________________________________________

You can also call us to use your VISA or MASTER CARD to make your memorial gift. Call (757) 221-1599 (EST).