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Printable Donation Form

Printable Donation Form

 Email

Printable Donation Form


Thank you for your interest in supporting Chabad House on Wheels! Your contribution will help us provide vital information and services to people across the globe.

Please make out your check to Chabad House on Wheels and send it to:

Chabad House on Wheels
P.O. Box 2591
Miami Beach, FL 33140

If you'd like to give us more specific information or would like to give us your credit card information by mail, please print and fill out the form below and send it to the same address.

Thank you very much!

Rabbi Zev Katz
Director, Chabad House on Wheels

Payment Method:

tinybox.gif Enclosed is my check
tinybox.gif Please charge my credit or debit card account using the information provided below.

I'm happy to make a tax-deductible contribution to Chabad House on Wheels of:
tinybox.gif $__________ tinybox.gif $500   tinybox.gif $250   tinybox.gif $100   tinybox.gif $50   tinybox.gif $25  

tinybox.gif American Express   tinybox.gif MasterCard   tinybox.gif VISA

Card Number:  ________-_________-_________-_________   Exp. Date (mm/yy) ______/______

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Your First & Last Name: ______________________________________
Address: ______________________________________
  ______________________________________
City, State, Zip: ______________________________________
Country
(if outside U.S.A.)
:
______________________________________
E-Mail address: ______________________________________
Daytime Phone: (____)______________________
Evening Phone: (____)______________________

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If you would you like this gift to be a tribute, please answer the following:

SELECT ONE.

This gift is...
   In Memory of
   In Honor of

To Mark a Special Occasion: 
   Birthday
   Bar/Bat Mitzvah
   Anniversary
   Other _____________


Honoree's Name:

_____________________________________

 

To have notification card(s) sent, please complete the following.

I would like a notification card without the gift amount mailed to:

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Name: ______________________________________
Address: ______________________________________
  ______________________________________
City, State, Zip: ______________________________________
Country (if outside U.S.A.): ______________________________________
From (Your name as you would like it to appear on the card): ______________________________________

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I would like a second notification card without the gift amount mailed to:

Name: ______________________________________
Address: ______________________________________
  ______________________________________
City, State, Zip: ______________________________________
Country (if outside U.S.A.): ______________________________________
From (Your name as you would like it to appear on the card): ______________________________________________

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