MARYLAND BICHON FRISE RESCUE, INC. DONATION FORM

If paying with VISA or MasterCard, print this form, fill out, and fax to Jill at 301-762-6422. If no fax available, charge donations may be phoned in to 301-762-6022 between noon - 9 PM Eastern time. If paying by check or money order, print and complete this form and mail with payment. Make checks payable to MARYLAND BICHON FRISE RESCUE, INC. and mail to MBFR - Jill Siegel / 13400 Valley Dr. / Rockville, MD 20850.

Cardholder Name
Billing Address
City, State, ZIP
Daytime Phone
Email Address
Form of Payment:	VISA ____ MasterCard ____ Check/Money Order ____
Credit Card #
Expiration Date	(mm/yyyy)
CVV2/CVC2/CID 3-digit # on back of card

Enclosed is my tax deductible contribution of $ _____________________

My donation is:

____ A general donation to Maryland Bichon Frise Rescue, Inc.

____ A donation to the Hendel-Peppard Senior Bichon Fund, to help pay costs of hospice care for older bichons in Rescue

____ In Memory Of: ________________________________________________________

____ In Honor Of: _________________________________________________________

Please send an acknowledgement to:

____ Me, at the address listed above, and/or

Name __________________________________________________________________

Address _________________________________________________________________

City, State, ZIP Code _______________________________________________________

Maryland Bichon Frise Rescue, Inc. is a Maryland corporation and all-volunteer, nonprofit organization.
Maryland Bichon Frise Rescue, Inc. is recognized by the Internal Revenue Service as tax exempt pursuant to
Section 501(c)(3) of the Internal Revenue Code. All donations are 100% tax deductible.

Thank you very much for helping bichons in need!