PEORIA MEDICAL SOCIETY ALLIANCE

HOLIDAY SHARING CARD

This is the time of year we remember those less fortunate.

Please be generous! You may designate your gift to one or more of the areas listed below.

Deadline for acknowledgement in card: December 8, 2018

*Questions? Contact: Darlene Violet (309) 240-8597, Becky Lagouros (309) 648-6921, Camilla Rabjohns (309) 696-3333

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Donation

* Mandatory fields
*First name
*Last name
Title
*Email
Office Number
Fax Number
Office Address
Office City/State/Zip
Website Address
Home Phone
Cell Phone
Work Phone
 Areas of Contribution
Please designate your gift to one or more of the following areas.
*Amount ($USD)
Levels:
Platinum $200+
Gold $150-$199
Silver $100-$149
Bronze $50-$99
*Contributor (name as you would like it to appear on the card):

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