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Name:
___________________________________________________________________________________
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Company:_________________________________________________________________________________
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Address:__________________________________________________________________________________
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City:__________________________________________________________
State:_____ Zip:_____________
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Phone:_____________________
Email:_________________________________________________________
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Amount of donation:
□ $50
□ $100
□ Other (enter amount) ___________________
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Please explore if your
company will match your charitable donation.
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complete this section and mail or fax to Kathy Chapman |
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Make check payable to PTTC and mail the
form along with your check to: |
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Name on card: _______________________________________ |
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Kathy Chapman
PTTC
PO Box 710942
Oak Hill, VA 20171
A receipt will be provided.
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Billing address:_______________________________________ |
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___________________________________________________ |
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Card type:
VISA
MC AMEX
DISCOVER
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Card
#:_____________________________________________ |
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Expiration: ___/_____ CVC (security code):
______ |
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