Donation Form

CARLOS OTIS STRATTON MOUNTAIN

MEDICAL CLINIC

P.O. Box 617, Stratton Mountain, Vermont 05155

802-297-2300 Fax: 802-297-3412

Donor Information

* Required Fields

Donation
Amount		Donation Level
	Complete the following fields if this gift is a tribute. (optional)
Type of Tribute
Tribute Name
Title
First Name
Last Name
Address
Address 2
City
State/Province
Zip/Postal Code
Email

Contact Information
* First Name
* Last Name
Company Name
* Address
* City		* State/Province
* Zip/Postal Code
* Home Phone		Work Phone
* Email

Credit Card Information
Card Holder Name

* Card Account Number
Expiration Date
* Security Code The 3 or 4 digit Security Code (CVV2) can be found on the back of your credit card. For American Express, the Security Code (CID) can be found on the front of the card.

Billing Address
Same As Above
* Address
City	State/Province	* Zip/Postal Code
Email

ALL DONATIONS ARE TAX DEDUCTIBLE FOR INCOME TAX PURPOSES

For gifts of securities, please contact the Clinic for details at 802-297-2300 or email [email protected]

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