MBC

8959 SW Barbur Blvd, Suite #101

Portland, Oregon 97219

 

CONTRIBUTOR INFORMATION

PLEASE CAREFULLY PRINT ALL INFORMATION

(Your personal information is kept confidential)

All information must be the same as printed on your credit card

 

Last Name: ________________________________

First Name: _______________________________

MI: ____

Street Address: __________________________________________

City: ____________________ State _____ Zip ________________

Telephone Number: (______)_____________________

email Address:______________________________________________________

 

A ONE-TIME DONATION, IN THE AMOUNT OF:   (please circle)

␣ $5,000 ␣ $2,500 ␣ $1,000 ␣ $ 500 ␣ $100 ␣ $50 ␣ Other:$________________

 

A REPEATING DONATION, AS FOLLOWS:

A sum of $ ______

Once Every ␣ Month ␣ Quarter ␣  Year, (please circle)

amounting to an Annual Total of $ ________________

Month and Year the donations begin and end_________________________

 

CHECK ENCLOSED: Please make checks payable to MBC

Please bill my credit card: (circle one)         Visa           Mastercard

Account number:__________________________________

Expiration Date: ___________________________________

Three digit Code (CVV):____________________________

Signature:________________________________________

 

My Contribution will Benefit the MBC General Fund/Teacher Training Fund

 

• MBC is a 501(c)(3) non-profit organization

• Payments must be received before the end of the year to be eligible for a tax

   deduction in that year.

• There is no minimum contribution amount.

For more information please visit or call 503-233-6747 or write to

info@meditationinoregon.org