Check Donation Form

IMPORTANT: You must enclose this form with your donation to the address below. Without this information,we will not be able to credit these funds to the Ambulance fund raising campaign.
Mail this form and your donations to:
ICUCHI 5832 Lebanon Rd Alexandria,VA 22310

Donor Name

Donation Amount

Check #

Phone:

Address:

City

State

Zip

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You will receive an appreciation letter for your donation, including the federal ID # of ICUCHI for your information.
Make copy of this form and mailed checks for your records.

Comparte con tus amigos.