LSU HEALTH SCIENCES FOUNDATION IN SHREVEPORT – CREDIT CARD TRANSMITTAL by wulinqing

VIEWS: 11 PAGES: 2

									                                                                                                         Submit by Email                Print Form


         LSU HEALTH SCIENCES FOUNDATION IN SHREVEPORT – CREDIT CARD TRANSMITTAL


                             Date Submitted            Department Name
                                All documentation indicating the donor intent and restrictions should be attached.
 The Foundation will automatically receipt all gifts of $5 and above. Please feel free to personally acknowledge these gifts.
 Account #     GL Code             Payor’s Name                                Brief Description                      Amount         Designation
                                                                                                                                       (Check One)
                                                                                                                                     Donation
                                                                                                                                     Sales
                                                                                                                                     Seminar
                                                                                                                                     Memorial
  Contact
                                                                                                                                     Other
Information:
               Telephone #             Address:                                City                     State            Zip

Credit Card    Visa      Mastercard Discover      American
Information:                                       Express
                                                                        Credit Card Number            Exp. Date      Security Code

 Account #     GL Code             Payor’s Name                                Brief Description                      Amount         Designation
                                                                                                                                       (Check One)
                                                                                                                                     Donation
                                                                                                                                     Sales
                                                                                                                                     Seminar
                                                                                                                                     Memorial
  Contact
                                                                                                                                     Other
Information:
               Telephone #             Address:                                City                     State            Zip

Credit Card                                       American
               Visa      Mastercard Discover
Information:                                       Express
                                                                        Credit Card Number            Exp. Date      Security Code

 Account #     GL Code             Payor’s Name                                Brief Description                      Amount         Designation
                                                                                                                                       (Check One)
                                                                                                                                     Donation
                                                                                                                                     Sales
                                                                                                                                     Seminar
                                                                                                                                     Memorial
  Contact
                                                                                                                                     Other
Information:
               Telephone #             Address:                                City                     State            Zip
                                                  American
Credit Card    Visa      Mastercard Discover
Information:                                       Express
                                                                        Credit Card Number            Exp. Date      Security Code

 Account #     GL Code             Payor’s Name                                Brief Description                      Amount         Designation
                                                                                                                                       (Check One)
                                                                                                                                     Donation
                                                                                                                                     Sales
                                                                                                                                     Seminar
                                                                                                                                     Memorial
  Contact
                                                                                                                                     Other
Information:
               Telephone #             Address:                                City                     State            Zip

Credit Card                                       American
               Visa      Mastercard Discover
Information:                                       Express
                                                                        Credit Card Number            Exp. Date      Security Code




                                          Submit to the LSUHS Foundation via campus mail.
                               Should you have any questions please contact the Foundation – 861-0855
                                                                 Page 1 of 2
         LSU HEALTH SCIENCES FOUNDATION IN SHREVEPORT – CREDIT CARD TRANSMITTAL


                                Date Submitted                                  Department Name
                                All documentation indicating the donor intent and restrictions should be attached.
                                The Foundation will automatically receipt all gifts of $5 and above.
                   Total Visa
                                                                  Total MasterCard

                  Total Discover
                                                                  Total American Express

                                                                  Total - Credit Card Deposit



Prepared by:                                                                    Title:
                 Please Print

Signature:                                                                      Phone:                      E-mail:


                                                        FOR FOUNDATION USE ONLY




                                      Submit to the LSUHS Foundation via campus mail.
                           Should you have any questions please contact the Foundation – 861-0855
                                                                  Page 2 of 2

								
To top