Donation Form


American Red Cross
P.O. Box 37243
Washington, D.C. 20013




Gift Information

Donation Amount: $ 1874.62
Designation: Hurricane Katrina  

Please check that your name and address are correct
to ensure proper preparation of your receipt for tax purposes.


Today's Date: Sunday, October 9 , 2005
Name: E.T. Samples, President
Company/Organization: Redland District Lions Club
Address: P.O. Box 700196
City: Goulds State: Florida ZIP: 33170
Country: US
Telephone Number: 305.247.3721
Email Address:       I may be contacted by e-mail.

Check or Credit Card information.

Please make checks payable to American Red Cross. If you wish to use a credit card, please complete the information below and mail in this form to the address listed at the top of this page. Thank you for your support.

Name on Card: ______________________________________________
Card Type: ______________________________________________
Account #: ______________________________________________
Expiration Date: ______________________________________________