Prevent Child Abuse
Illinois
(Payment Option #2)
City State Zip
My gift is in honor of:
Angel's Confidential
Please send Acknowledgment to:
Angels Confidential
RR 3 Box 380
Hanna City, IL. 61536-0380
* YES, I (or my spouse) work for a company that will match my gift.
Company Name:
If so, then please enclose your company matching gift form.
Credit Card Information:
VISA DISCOVER MASTERCARD AMERICAN EXPRESS
Name on Credit Card
Credit Card Number:
Expiration Date:
Amount to be Charged:
Signature:
Upon acceptance, please mail completed form to address below along full prepaid donated cost.
528 South 5th street, suite 211
springfield, Il 62701
or FAX to: (217) 522-0655
Thank You!