Tax Deductible Contribution Form

Amount Donation:

$20 $50 $100 $500 $1,000 $2,000 Other:

I would like to pledge:

$ , to be made in equal payments. I am mailing a check

or my Credit Card Number is:

Visa Master Card Expiration Date:

I would like my donation to be spent where it needed most.

I would like to earmark my donation to specific project (please name)

Mailing Address:

Line 1:

Line 2:

Email:

Home phone:

Work phone: Employer:

Does your employer have a matching fund program? Yes No

If so, please provide contact information:

Do you have goods or services you wish to donate to the Hawaii Wellness Institute? If so, what?

Do you wish to volunteer your time to the Hawaii Wellness Institute? Yes No

Are you willing to forward our appeal to a friend? Please feel free to do so! Yes No

Thank You So Much for Your Generosity!
The Staff at the Hawaii Wellness Institute.