[ ] $15 / month [ ] $30/ month [ ] $ _____a month Or [ ] quarterly
[ ] once a year for [ ] $180 [ ] $360 [ ] Other $___________
PRINT NAME __________________________________
____Check enclosed (make payable to Hadassah)
____Charge my donation to: MC Visa AmEx Discover
Name as it appears on card: _____________________________________________
E-mail address: _________________________________________________
My employer has a Matching Gifts program.
Please contact me @ Phone #:
By checking one of the above monthly, quarterly or annual payment options, I agree that my credit card will continue to be charged each year as directed above and that this authorization for automatic debit remains in effect until I cancel or transfer my method of payment. I agree
to notify Hadassah upon the expiration or cancellation of the above credit card and to supply Hadassah with updated credit card or other payment information. I understand that I may cancel the automatic renewal payment option at any time by contacting Hadassah.
Please fill out form above and mail to:
Hadassah, 50 West 58 Street, PO Box 745, New York, NY 10101-0745 (watch for notification of our new address coming soon)
or call 800.928.0685
or email email@example.com
or donate online at www.hadassah.org/chaisociety.