Tobacco Free Rhode Island

Donation Form
Make a Donation That Will Save Lives

To send donations by mail:

  1. Make your check payable to the American Lung Association of the Northeast.
  2. In the memo line, write "TFRI."
  3. Print and complete this form, and mail with your check to:
         Tobacco Free Rhode Island
         c/o American Lung Association of the Northeast
         260 West Exchange Street, Suite 102B
         Providence, RI 02903

PLEASE PRINT CLEARLY

Full Name

______________________________________________________________________

Street

______________________________________________________________________

City

______________________________________________________________________

State/Prov

__________

Zip

__________

Phone

__________________________________________________

E-Mail

__________________________________________________

 

 

 

Choose One:

  Regular donation
  In Honor of  (Choose this option if the person you are honoring is living)
 In Memory of  (Choose this option if the person you are honoring is deceased)

Honoree Title

__________ (Example: Mr., Mrs., Ms., Miss, Mr. & Mrs., Dr., etc.)

Honoree Name

______________________________________________________________________

 

If you would like a photograph of your honoree(s) to be featured with your donation on the Gifts for Life Wall, please mail it with this form.

 

 

I wish to give anonymously (your name will not be listed on our Gifts for Life Wall or in any public reports).

Credit Card Type

 

Credit Card Number

______________________________________________________________________

CVV Number
What's this?

__________

Expiration Date

Month: _____   Year: _____

 

Signature

______________________________________________________________________

© Copyright 2010-2017 Tobacco Free Rhode Island. All rights reserved.
c/o American Lung Association of Rhode Island 260 West Exchange Street Providence, RI 02903

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