| First Name |
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| Last Name |
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Contact Address |
| Address |
|
| Address |
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| City |
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| State |
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| Zip |
|
| Phone |
|
Billing Address Same As Contact |
| Address |
|
| Address |
|
| City |
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| State |
|
| Zip |
|
| Phone |
|
| |
| Email |
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| Gift Amount: |
Other Amount:
|
| Allocate
Funds |
(specify dollar amount for
any area below totalling your
Gift amount above) |
| LSS General Fund |
|
| Food Pantries |
|
| Faith Mission |
|
| The Rose of Concern Fund |
|
| Disaster Response |
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| Southeast Ohio Ministries |
|
| Disaster Preparedness Training Payment |
|
| Other |
Give to |
| |
| Name on Card |
|
| Card Number |
|
| Expiration Date |
xx/xxxx |
| Card Type |
|
|
Please tell us how you heard about us: |
|
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