South Shore Health and Educational Foundation
Credit Card Donation Form

Date:

Name:

Address:

Street:

City:

State:

Zip:

Telephone:

Home:

Work:

E-Mail:

Please designate my gift to:

Most urgent need

Other:

Pledge Amount:

$

Gift Amount:

$

My Company:

Matches*:

$

*Please forward a matching gift form to: South Shore Health and Educational Foundation.

My total gift amount will be:

$

Please apply my gift to my:

Visa
MasterCard
Amex

Credit Card No.

Exp.

Name as it appears on card:

Fax this form to 781-340-4269

Or mail to:

South Shore Health and Educational Foundation
55 Fogg Road
Weymouth, MA 02190-2455

Thank you for your generosity.