SECURE ONLINE GIFT FORM (SSL Secure)

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Gift Amount

For gifts of $1,000 or more, you are recognized as a member of

The Bertha L. and Moses H. Cone Society. Thank you.

Please note the frequency of your donation.

Donation Amount*
  • $100
  • $500
  • $1,000
  • Other $

Gift Purpose

Designation*
  • Area of Greatest Need
  • Cancer Patient Support (including Alight)
  • Heart and Vascular Center
  • Women's and Children's Center Fund
  • Other
Other - type designation here

Honors and Memorials

This gift is:
  • In Memory of
  • In Honor of
Honoree's Name
For the following occasion:

 

Please Notify:

Name
Address
City
State
Postal Code
Country

Your Information

 

Spouse/Partner:

Title
First Name
Middle Initial
Last Name

Enter address, city, state, and postal code

as filled with your financial institution.

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Daytime Phone*
List name(s) in donor recognition materials as
Check if you want this gift to be anonymous
  • and your name(s) not to be published

 

For assistance with this form or information about other giving opportunities, please call 336.832.9450 during business hours (8:30 am –5 pm Eastern) or email institutional.advancement@conehealth.com.

 

Thank you.

 

Payment Information

Amount*
$
Name on Card*
Card Number*
Additional Comments

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