Crossroads Medical Mission
P.O. Box 16852
Bristol, VA  24209-6852

276-466-1600 fax: 276-466-2800

Please accept my contribution of $____________________. I understand that my funds will be used to provide medical care to the underserved, and that I will receive no goods or services in return.

 

Name _________________________________________________________________

 

Address _______________________________________________________________

 

City, State, Zip __________________________________________________________

_______My check is enclosed.

_______I would like to pay by credit card (circle one): VISA, MASTERCARD, AMERICAN EXPRESS

Card number: __________________________________. Expiration Date: ____________

 

I want this donation to go to (select one on the following):

______ general fund

______ endowment

______ memorial/honorarium fund 

This gift is    In honor of _________________  In memory of ________________

 

Please send acknowledgement to: (if different from above): ______________________

Address____________________________________________________________

City, State, Zip ______________________________________________________

E-Mail ____________________________________________________________