Print, fill and mail this form to: 312 East Alta Vista, Ottumwa, Iowa, 52501

I/We want to become a "Friend of Hospice" or join the "Circle of Friends"


Name(s):                                                                                                                             
Address:                                                                                                                              
City/State/Zip:                                                                                                                     
Phone                                                                                                                                 

 My check (payable to Friends of Hospice) for $                               is enclosed.
 My check (payable to Circle of Friends) for $250 or more is enclosed.
Visa    MasterCard
Account #                                        Exp.Date:                   Signature:                                 

In Memory of (deceased) or Honor of (living):
                                                                                                                                         

Please notify the following person about this gift:
Name:                                                                                                                                
Address:                                                                                                                             
                                                                                                                                         

Your gift is tax deductible within the limits of the law.