Galatia Natural Disaster Response Team

Donation Form

First Name___________________________________

Last Name___________________________________

Billing Address________________________________

Zip Code____________________________________

City/State____________________________________

Day Phone___________________________________

Evening Phone________________________________

E-Mail______________________________________

Fax________________________________________

Type of Donation______________________________

Donation in honor of:___________________________

Donation Amount  $____________________________

Donate to the Galatia Natural Disaster Response Team