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Friends of Westside Health Contribution Form

Please print and complete this form, and mail to: 

Friends of Westside Health    

1802 W. Fourth Street

Wilmington, DE 19805

___  I would like to become a Friend of Westside Health by contributing:

         $ ___________________.

___ I wish to pledge the above amount over the next year.  Please bill

       me quarterly.

___ I wish to be a Friend by pledging and endowment.  Please contact

       me.

___ I wish to be a Friend by volunteering my time.  Please contact me.

Please make checks payable to Westside Health, Inc.

Please bill my credit card.  Circle one:       VISA       MC      

        Amount: $ ______________________________

        Card #: _________________________________  

        Exp. Date: ________ / ________

        Signature: _____________________________________________

   Name: ___________________________________________________

   Address: _________________________________________________

   City: _______________________  State: ______  Zip: _____________

   Home Telephone: __________________________________________

   Work Telephone: ___________________________________________

   Email: ___________________________________________________

Thank you for being a Friend and helping us to achieve our mission.

All gifts are tax deductible.