Please print this form, complete all sections,
include your credit card information and signature (or enclose
your check), and mail to:
Helen Hayes Hospital Foundation
Route 9W, West Haverstraw, NY 10993
and thank you for your support of Helen Hayes Hospital!
I/We would like the following:
Bench Plaque
$1,000
Brick
$100
Please print wording as you
wish it to appear on your plaque or brick.
Photocopies can be used for additional plaques or bricks.
Bench plaques
can contain a maximum of three (3) lines of text with thirty
(30) characters per line including spaces and punctuation.
Bricks can
contain a maximum of three (3) lines of text with fourteen
(14) characters per line including spaces and punctuation.
Name:
Company Name:
Address:
City:
State & Zip
Phone:
E-mail
My check is enclosed payable to: Helen
Hayes Hospital Foundation
Charge my (check one):
Visa
Mastercard
Discover
AMEX
Account#
Exp. Date
Signature
Helen Hayes Hospital
Foundation is a publicly supported tax-exempt charitable organization.
A financial statement is on file with the New York State Department
of Law, Charities Bureau, 120 Broadway, 3rd Floor, New York, NY
10271.
