Citizens Honor/Memorial Form

Gift Information

Honor and Memorial Gifts to Citizens Options Unlimited

An honor/memorial donation is a meaningful way for friends and family to honor someone special, recognize a significant achievement, celebrate a special day or make a gift in honor of someone who is deceased. Your contribution supports programs and services which strive to improve the lives of people with intellectual and developmental disabilities.

Field Is Required Enter A Gift Amount:

$500.00

$250.00

$100.00

$50.00

$25.00

Enter Amount ($10.00 Minimum)

Enter amount

Honor / Memorial Information

I would like to give in Honor/Memory of:

Honoree First Name:

Honoree Last Name:

Send notification of my donation to:

(An acknowledgemet card created by a person supported through our programs will be sent to the Recipient listed below. The amount of the donation does not appear on the card.)

Title:

Notification Recipient First & Last Name:

Recipient Relationship to Honoree/Deceased (spouse, mother, sister):

Street 1:

Street 2:

City:

State:

ZIP/Postal Code:

Comments

Billing Information

Is this donation on behalf of a Company or Employer?

Yes

Company/Employer:

Title:

First Name:

Last Name:

Street 1:

Street 2:

City:

State/Province:

ZIP/Postal Code:

Email Address:

Phone Number:

Credit Card Information:

Credit Card Type:

Credit Card Number:

Expiration Date:Select month of credit card Select Expiration Year

CVV Number: What is this?

If you donate and have not already registered, you will receive periodic updates and communications from AHRC Nassau.