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Northwest Hospital Online Donation Form

Thank you for supporting Northwest Hospital with an online gift. We are a 501 (C)(3) non-profit; therefore, all gifts are tax-deductible as allowed by law.
Donation Levels 
  Level
    $1,000 
    $750 
    $500 
    $250 
    $100 
    $50 
    $25 
* required information
Donation
Other
I would like to make a one-time gift for the following amount:
:* $
I would like to make a recurring gift.
Gift Amount* # of Payments Payment Frequency Total Gift Amount
$ X = $
NOTE: This transaction will count as the first payment toward your total gift amount.

Gift Designation
I would like to desginate my gift to the following:
 

Donor Information
If your gift designation is not listed, please add it here:
Title:
First Name:*
Middle Initial:
Last Name:*
Company Name:
Email:*
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Phone:*
Business Phone:
Cell Phone:
Fax:
Country:

Payment Information

Payment Method
:*
:*
:*   Explain
Credit Card Type:*
                  
Credit Card Expiration:*

Billing Information
If the billing information is the same as the contact information check this box.
If not please fill out the information below:
:*
:
:*
State:
:
:*
Country:*

Matching Gift Information
Will this donation be potentially matched?
If you know the following information regarding the matching gift, please complete.
Company Name:
Matching Gift Amount:$

Honor and Memorial Gifts
Make your donation in remembrance of a loved one or to honor a special individual or event. If you provide us with a notification name and address below, we will send a special card to the person, or the family of the person, in whose name the gift is made.
In Honor Of / In Memory Of:
Tributee Name:
Notification First Name:
Notification Last Name:
Notification Address 1:
Notification Address 2:
Notification City:
Notification State:
Notification Zip:
Special Instructions:
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