Credit Card Donation

Please complete the form below to make a gift by credit or debit card. A minimum gift of $20 is required to receive an Employee Giving t-shirt.

Please contact Kate Leahy in our Development Office at development@mainehealth.org, or 207-662-2669, with any questions or concerns.

Donation Information

Amount:

Gift

$ 1,000.00

Gift

$ 500.00

Gift

$ 250.00

Gift

$ 100.00

Gift

$ 50.00

Gift (min. required to receive t-shirt)

$ 20.00

Other

Additional Information

Your t-shirt will be delivered to you within 7 business days. In order to do so, you must provide detailed information about your office location. Unfortunately, we cannot mail to home addresses.

Donation Type:

Physical Work Location address,building,floor etc.:

T-shirt :

Billing Information

Title:

First name:

Middle name:

Last name:

Country:

Home Address lines:

City:

State:

ZIP:

Phone:

Email:

Confirm Email:

Payment Information

Payment Method:

Credit Card

Direct Debit

Cardholder's Name:

Credit Card Number:

Card Type:

Valid From:

/	(Maestro/Switch/Solo only)

Card Expiration:

Issue Number:

(Maestro/Switch/Solo only)

Card Security Code:

Note: The Card Security Code is not required for Maestro, Switch and Solo cards.

Working together so our communities are the healthiest in America.

Credit Card Donation

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