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DEDICATION INFORMATION

1) I would like to dedicate my donation: (Choose one)

  a) In Memory Of:___________________________________________(Name)

  b) In Recognition Of:________________________________________(Name)

  c) In Honor Of:____________________________________________(Name)

  d) Thinking Of You:_________________________________________(Name)

2) For what Occasion

  Please print here:_________________________________________________

  ________________________________________________________________

  Check here:__ If you would like Gleaners Dispatch, Inc. to send an appropriate
  acknowledgement of my Donation Gift to:

  Name:________________________________________________________

  Address:______________________________________________________

  Telephone (Optional):__________________

3) Donation To Gleaners Dispatch, Inc. Is Being Made By:

  Your Name:___________________________________________________

  Address:_____________________________________________________

  City/State/ZipCode:________________________________________

  Telephone (Optional):__________________

4) My GIFT

  Of $___________ -or- [$50] [$100] [$250] [$500] [$1,000] [$5,000] -(circle one)
  Is Being Paid in the Following Way:

  Check here: __ If you made an donation Online at www.gleanersdispatch.org website.

  Check Here: __ If your donation is a Check or Money Order Payable to Gleaners Dispatch, Inc. & mailed to:

    GLEANERS DISPATCH, INC.
    8207 103rd Street
    Jacksonville, FL 32210-6553
    (904) 777-6344

  Gleaners Dispatch, Inc. is an IRC 501c3 nonprofit charitable organization You will be sent a Year-End Contribution Receipt.

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