Monetary Donation Form

20 03

Monetary Donor Form

Please provide the following contact information:

* = required

Name	*
Title
Organization
Street Address	*
Address (cont.)
City	*
State/Province	*
Zip/Postal Code	*
Country	*
Work Phone
Home Phone	*
FAX
E-mail
URL

Please Send Acknowledgement Of My Gift to:

First Name
Last Name
Middle Name or Initial
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
E-mail

Credit Card Holder Name: (as it appears on credit card)

* = required

First Name	*
Last Name	*
Middle Name or Initial	*
Street Address	*
Address (cont.)
City	*
State/Province	*
Zip/Postal Code	*
Country	*
Work Phone
Home Phone	*
FAX
E-mail

Billing Information If Different From Above:

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Contribution Information:

In Memory Of: or In Honor Of:

Name

Credit Card Type: Credit Card Number:

* *

Expiration Date: Amount: Choose one of the following options:

*dd/mm/yy $ *

We, the students of Maryland Youth Maritime Academy thank you for your donation.

You are Donor #

FOR YOUR CONVENIENCE PLEASE PRINT AND MAIL THIS FORM WITH CHECK OR CREDIT CARD INFORMATION TO: Maryland Youth Maritime Academy, Inc. P.O. Box 29943 - South Station - Baltimore, MD 21230-9998. If you have any questions, please contact us at:

6280-I Foreland Garth - Columbia, 21045-3070 Tele/Fax (410) 715-5507 0r Tele/Fax (866) 415-6761.

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All rights reserved. Revised: 04/23/06