Pulaski Visa Credit Card Payment

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					                          Hensel Eckman YMCA
                ___________We Build People 2009__________

Donor Contact Information
Name:_______________________________________________
Company Name: ____________________________________
Address:___________________________________________
City: ________________ State: ______      ZIP: __________
Phone: ______________ (work) _____________ (home)
2008 Pledge: $______________(Enter amount)
Does employer have a matching gift program?
Yes    No     If so, name of firm: _________________
--------------------------------------------------------------
If donation is $1000 or more, does donor wish to participate in banner
program? ______
(If yes, campaigner should contact Suzanne Wantland ((540)980-3671)
to make arrangements.
--------------------------------------------------------------
Payment
1) ____ Check, payable to: Hensel Eckman YMCA
2) ____ Bank Draft: $___________ for _______ mos
3) ____ Credit Card Draft: $________ for _______ mos
  Credit Card Information:
      _____ VISA    _____ MASTERCARD
Account # _______________________ Exp Date _________
Name as it appears on card: _________________________
       Signature: _____________________________________

Please return this form to Suzanne Wantland,
                           c/o Hensel Eckman YMCA
                           615 Oakhurst Avenue
                           Pulaski, VA 24301

                         Thank you for your support!!!

				
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