Capital Gift Contribution Form
Thank you for your generous donation.
To make your gift by mail, please make checks payable to:
Eisner Pediatric & Family Medical Center
And mail to:
Eisner Pediatric & Family Medical Center,
Attention: Carl E. Coan, President & CEO
1530 South Olive Street, Los Angeles, CA 90015.
To make your gift by fax using your credit card, please print, complete and fax the form below to:
Attention Leslie Villavicencio, EPFMC
Fax: (213) 746-9379
A confirmation and note of appreciation of your tax-deductable contribution to EPFMC will be mailed to you at the address you provide in this form.
| Full Name: | ________________________________________ (Associated with your credit card) |
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| Address: | ________________________________________ (Associated with your credit card) |
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| City: | ________________________________________ | |
| State: | ____________________ Zip: ________________ | |
| Home Phone: | ________________________________________ | |
| Business Phone: | ________________________________________ | |
| Email Address: | ________________________________________ | |
| Donation Amount: | ________________________________________ | |
| Please bill my: | Visa Mastercard |
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| Credit Card #: | ________________________ Exp: _____ / _____ | |
| Signature: | ________________________________________ | |
| I would prefer to make the transaction over the telephone. | ||
| Please call me at: | Work Home |
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Questions? Please contact Leslie Villavicencio, Director of Development
Ph: (213) 746-1037, ext. 3474, or email lesliev@pedcenter.org
Ph: (213) 746-1037, ext. 3474, or email lesliev@pedcenter.org