ORDER FORM

Use this online form to create your message and pay by credit card. For other payment options or if you need assistance completing the form, please call 336.832.9450 during business hours or email fund.development@conehealth.com

INSTRUCTIONS

Select your message size Option and then check one of the boxes if it is in Honor of or in Memory of someone (select None if neither applies). In the box, type the name of person and additional information. To view examples of layouts, please refer to Plaque Choices. Note: Cone Health may edit content for readability.

Items marked bold are required fields.


Type name(s) and other information in box below. Box limits number of characters, including punctuation and spaces, based on Option you select.

Plaque Choices
Option A - Gift Amount: $1,200
Message Size: 6" x 10" - Maximum number of characters: 730
Honor Of   Memory Of   None

Option B - Gift Amount: $600
Message Size: 6" x 5" - Maximum number of characters: 365
Honor Of   Memory Of   None

Option C - Gift Amount: $300
Message Size: 3" x 5" - Maximum number of characters: 200
Honor Of   Memory Of   None

Option D - Gift Amount: $175
Message Size: 2" x 5" - Maximum number of characters: 85
Honor Of   Memory Of   None

Other

I am not able to participate in the Honor Walkway at this time. However, I am making a gift of $ to enhance cancer patient support services as well as to provide assistance for transportation, food and other necessities for indigent patients.


Notification
Honoree's name:
For the following occasion:
Please Notify:
Name:
Street Address:
City:
State:
Postal Code:
Country:

Donor Information
Preferred Title:
First Name:
Middle Initial:
Last Name:

Spouse/Partner Information (if applicable)
Preferred Title:
First Name:
Middle Initial:
Last Name:

Enter address, city, state and postal code
as filed with your financial institution.
Address Type: Home   Business
Street Address:
City:
State:
Postal Code:
Country:
Email Address:
Daytime Phone:

Recognition Preference
Please list my (our) name in donor recognition materials as:
I would like my gift to remain anonymous.

Credit Card Information
Amount: $
Name on Card:
Card Type:
Card Number:   (No Dashes or Spaces)
CVV2: Click here for CVV2 information.
Expiration Date: mm/yyyy

Matching Gift Company
My company will match my gift.
Company Name:

Other Information
I am interested in learning about other ways to Help Create Exceptional Care. Please contact me.

Comments

A formal acknowledgement letter will be mailed to you. The person or family of the person you have honored will be notified of your thoughtfulness. Thank you for your gift.

Contributions to Cone Health are tax deductible to the extent permitted by law. We do not sell or trade our mailing lists.


Security

Type the security code from the image below.

     

Questions? Call the Office of Fund Development at 336-832-9450

Office of Fund Development
1200 N. Elm Street, Greensboro, NC 27401