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