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Ways to Give

Donation Form

This donation form can be completed, printed, and then either mailed or FAXed to:

The Western Pennsylvania Hospital Foundation
4818 Liberty Avenue
Pittsburgh, PA 15224

FAX 412.578.4428

PDF version can be downloaded here.


DONOR INFORMATION: 
 Dr.    Mr.    Mrs.    Ms.    Miss    Mr. and Mrs.    Other
Name:

COMPANY INFORMATION
(This section should only be completed if the contribution is being made by a company. If you are donating as an individual, skip this section and proceed to "address.") 
Company Name:
Company Contact:
Title:

ADDRESS
Address:
City:
State:
Zip/Postal Code:
Country:
Daytime Phone:
Evening Phone:
Email Address:

GIFT AMOUNT
I would like to make a gift of:

CORPORATE MATCHING GIFT
Name of Corporation:

CREDIT CARD INFORMATION
Credit Card:  VISA   MasterCard   American Express   Discover
Card Number:
Expiration Date:
Security Code:
Name on Card:
Signature: ___________________________________


I WOULD LIKE MY DONATION TO BENEFIT:

West Penn Hospital 
 The hospital's most pressing need

Other  


RECOGNITION 
Donor recognition materials should list my/our name as 

 
This gift is anonymous.
 
My/our gift is being given in memory of 
My/our gift is being given in honor of 
Please notify the following person(s) that a honor/memorial gift has been made:
 Dr.    Mr.    Mrs.    Ms.    Miss    Mr. and Mrs.    Other
Name:
Address:
Address:
City:
State:
Zip/Postal Code:
Country:
Please list my/our name as:
Special Message: 

 

 

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