CLEVELAND PSYCHOANALYTIC CENTER
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All donations will be acknowledged by letter.

 
Cleveland Psychoanalytic Center
DONATION FORM
Please complete the following information about your gift.
Title
  

First Name

  
Last Name
 
Company Name
 
Street Address
 
City State Zip
 
Country
  
Phone
  
Fax
  
E-mail
  
Amount

$2,500
$1,000
  _____ I wish to receive future e-mail correspondence.
  _____ I wish to make this donation anonymously.
  _____ My company has a matching gift policy .
Payment Information
 
Credit Card Number
 
Name As It Appears on Card
 
Expiration Date
 
   
You may print out this form and fax it to: (216) 229-7321
Or mail this form
with your check to:

Cleveland Psychoanalytic Center
2460 Fairmount Boulevard
Cleveland Heights OH 44106

This gift is

 

____in honor of _______________________________________________

 

 

____in memory of _____________________________________________

Please send an additional acknowledgement to:

 

Name(s)______________________________________________________

Address_______________________________________________________

City State Zip__________________________________________________

Questions?
Contact Debbie Morse at(216) 229-5959.