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Printable Donation Form

Your gift to Maimonides Medical Center will support a broad range of life-saving services – funding vital research projects, graduate medical education and a host of medical services from pediatric to cardiac to cancer care and more.

Make a difference through a tax-deductible gift today. The information you provide here is secure and will not be shared. For more details, please read our Privacy Policy.

Please print the form below and mail it to:

The Development Office
Maimonides Medical Center
4802 Tenth Avenue
Brooklyn, NY 11219


Enclosed please find my tax-deductible donation made payable to the Maimonides Medical Center in the amount of:

__ US $25 __ US $50 __ US $100 __ US $250  
__ US $500 Other:_____      

Designation:

__ Where it's needed most __ Cancer Center __ Heart & Vascular Center
__ Stroke Center __ Infants & Children's Hospital __ Geriatric Care
__ Obstetrics __ Radiology/Imaging __ Surgery
__ Urology __ Women's Health __ Community Outreach
Other ___________________

Referral Source:

__ Google or other search engine __ Doctor recommendation __ A friend
__ Email __ Direct mail __ Website
__ I was a patient __ Family/friend of patient __ News story
__ Advertisement

If donating by credit card, please provide the following information:

Visa: _________
Mastercard: _________
AMEX: _________
Discover: _________

Credit Card Number_____________________________________

Expiration Date_________________________________________

Card Verification #_______________________________________

Name_________________________________________________

Address_______________________________________________

City/State/Zip/Country____________________________________

Phone_________________________________________________

Email__________________________________________________
Acknowledgement of donation will be sent via email

Signature_______________________________________________

 


 

Is this gift in memory of or in honor of someone? If so, please let us know for whom it is in tribute and to whom an acknowledgement should be sent.

In Memory of_____________________________________________

OR

In Honor of_____________________________________________

Acknowledgement should be sent to:

Name__________________________________________________

Address________________________________________________

City/State/Zip/Country____________________________________

Phone__________________________________________________

Donation From: __________________________________________

 

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Your Name:
Your Email:
Recipient Email:
Your Comments:
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Maimonides Medical Center    |    4802 Tenth Avenue    |    Brooklyn, NY 11219    |    718.283.6000    |