NCCC - St. Johnsbury Memorial Gift Fund
Thank you for your gift.
If this is a gift in memory of or in honor of someone, please complete the Memorial and Honorary Gifts section at the bottom of this form.
Donation Information
Amount:
Gift of
$ 250.00
Gift of
$ 100.00
Gift of
$ 50.00
Gift of
$ 35.00
Other
$
*
Additional Information
Frequency:
Weekly
Monthly
Quarterly
Annually
On:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Starting:
Ending:
Ending:
Corporate:
This donation is on behalf of a company
Anonymous:
I prefer to make this donation anonymously
Comments:
I am a D-H/Geisel Employee:
Yes
No
Billing Information
Title:
<Please select>
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
*
First name:
*
Last name:
*
Country:
UNITED STATES
ALBANIA
ANGUILLA
ARGENTINA
ARUBA
AUSTRALIA
AUSTRIA
BAHAMAS
BANGLADESH
BARBADOS
BELGIUM
BEQUIA
BERMUDA
BOLIVIA
BOTSWANA
BRAZIL
BRITISH VIRGIN ISLANDS
CANADA
CHILE
COLOMBIA
COSTA RICA
CROATIA
CZECH REPUBLIC
DENMARK
EGYPT
ENGLAND
FINLAND
FRANCE
GERMANY
GHANA
GREECE
GRENADA
GRENADINES
HOLLAND
HONDURAS
HONG KONG
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN
IRELAND
ISRAEL
ITALY
JAMAICA
JAPAN
KENYA
LUXEMBOURG
MALAYSIA
MEXICO
MICRONESIA, Federated States of
NEPAL
NETHERLANDS
NEW ZEALAND
NIGERIA
NORWAY
PANAMA
PEOPLES REPUBLIC OF CHINA
PHILIPPINES
PORTUGAL
PUERTO RICO
ROMANIA
SAUDI ARABIA
SCOTLAND
SINGAPORE
SLOVENIA
SOUTH AFRICA
SOUTH KOREA
SPAIN
SRI LANKA
SWEDEN
SWITZERLAND
TAIWAN REP. of CHINA
TANZANIA
THAILAND
TURKEY
UAE
UNITED KINGDOM
VENEZUELA
via GENEVA, SWITZERLAND
WEST INDIES
ZIMBABWE
*
Address lines:
*
City:
*
State:
<Please Select>
Not
*
AA
AE
AP
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
**
AB
BC
MB
NB
NL
NT
NS
NU
ON
Ont
PE
QC
SK
YT
***
AS
CZ
FM
Gau
GU
Mah
MH
MP
PW
PR
SG
TAI
VD
VI
---
ACT
NSW
N.T
QLD
SA
TAS
VIC
W.A
*
ZIP:
*
Phone:
Email:
*
Payment Information
Fundraising activities on behalf of the Norris Cotton Cancer Center is conducted by Dartmouth-Hitchcock Health, a 501(c)(3) recognized charity by the IRS (EIN#26-4812335), for the benefit of NCCC. Your gift will appear on your credit card statement as a payment to "D-HHealth Donation".
Cardholder's Name:
*
Credit Card Number:
*
Card Type:
Visa
American Express
Discover
MasterCard
*
Card Expiration:
01
02
03
04
05
06
07
08
09
10
11
12
/
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
*
Card Security Code:
*
Matching Gifts
My company will match my gift
Company:
*
Tribute Information
Type:
in memory of
in honor of
*
Name:
*
First name:
Last name:
*
Mail a letter on my behalf
*
Copyright 2016 Dartmouth-Hitchcock. All rights reserved.