Please enter your:
Preferred title (Dr., Mrs., Mr., Miss, Ms., no title)
Name:_________________________________________________________
Street Address:_________________________________________________
City:_________________________ State ___________ Zip _____________
Home Phone: (____)____-________Business Phone: (____)____-________
E-Mail Address:________________________________________
Gift/Pledged Amount: $______________Pledge period: ____Years
Your Signature:__________________________________________________
Please send me a reminder notice on:_________________________
Gift Restrictions, if any:___________________________________________
In memory of:___________________________________________________
Memorial notification address, if different from above: ______________________________________________________________
___Yes, I would like information on how to remember the Foundation in my will or in my estate.
To Make Gift/Pledge, print this and mail with your check to the address below (be sure to sign sheet if this is a pledge). For more information, or if you have questions, please call or write:
Mercy Medical Center Foundation - North Iowa
1000 4th Street, S.W.
Mason City, Iowa 50401
PHONE: 641.422.7740
FAX: 641.422.5664