"Carlos Otis Stratton Mountain Clinic Donation Form"
 
Donor Information:
Name:
Company:
E-mail:
Phone:   with Area Code
Street Address: Line 1 --

Line 2 --
City: State:  
Zip/Postal Code: Country (if not USA):
 
FOR CREDIT CARD USE:  VISA        Mastercard        Discover        American Express      
Credit Card Number: - - -

Exp. Date     /

Donation amount:  $ Company matching gift form enclosed:
ALL DONATIONS ARE TAX DEDUCTIBLE!

Donation information:

1. Complete and print the Donation form.
2. Mail or hand deliver the completed form to the address below..

To donate securities please contact the Clinic for delivery instructions.

For additional information please call the Clinic. 802-297-2300.

Thank you in advance for your donation.

The Staff of The Carlos Otis Stratton Mountain Clinic.

Make checks payable to Carlos Otis Stratton Mountain Clinic, Inc., and send to:
     Carlos Otis Stratton Mountain Clinic, Inc.
     P O Box 617
     Stratton Mountain, VT 05155