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FAX OR MAIL-IN
ORDER FORM |
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QUESTIONS? Call (887) 434-8454 M-F or email us at contactus@haitichildren.com |
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| Certificate | Donation Amount | Quantity | Donation Amount |
| $5 Donation Certificate | $5 | * ( ) | |
| $10 Donation Certificate | $10 | * ( ) | |
| $25 Donation Certificate | $25 | * ( ) | |
| $50 Donation Certificate | $50 | * ( ) | |
| $100 Donation Certificate | $100 | * ( ) | |
| $1000 Donation Certificate | $1000 | * ( ) | |
| Other Donation Certificate | $ | ||
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Total Donation |
$ | ||
Name: |
Phone: |
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Address1: |
Email: |
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Address2: |
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City, State, Zip, Country: |
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| Payment Methods Money Order Check (include with mail) | |||
| Credit
Card (Visa, Master Card, AMEX) Credit card Number Number: _________________________ Expiration Date: ______________________ Signature: ______________________ |
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