Hope Center, Inc.
666 Southwest 4th Street,  Miami, Florida 33130
Tel:  305.545.7572   ·   Fax: 305.325.0382
Print out this form and fax it to: A. Kossiver at 305.325.0382

Sponsor/Donor Information: 
           Name:
First Name                                   Last Name
Address:


City                                                    State                   Zip Code
Telephone:
Daytime Phone.  Please include area code.

Evening Phone.  Please include area code.
Email Address:

Gift Information:  
     Contribution Amount: .00
Credit Card Type:
(i.e., Visa, MasterCard, AmEx, Discover, etc.)
Name as it appears on Card:
Credit Card Number:
Credit Card Expiration Date:     
Month                                    Year

Order Plaques, Bricks, Hope-a-Grams:
I would Like to order: Plaque:             Quantity    
Brick:                Quantity    
Hope-a-Gram:   Quantity    

Volunteer Opportunities:
Please send me information on: Service Projects
Special Friends
Support Services