Minneapolis Heart Institute Foundation Donation Form

Minneapolis Heart Institute Foundation

Print out this form and mail to:

Minneapolis Heart Institute Foundation
920 East 28th Street
Suite 100
Minneapolis, MN 55407

Or, if making a gift using your credit card, you can fax the form to 612-863-3801.

Donation Amount:

Circle One:

$15 $25 $50 $100
or
Other $___________

Name:

____________________________________

Address 1:

____________________________________

Address 2:

____________________________________

City:

____________________________________

State:

____________________________________

Zip:

____________________________________

Country:

____________________________________

Email:

____________________________________

Credit Card Information

Number:

____________________________________

Type:

____________________________________

Expiration Date:

____________________________________

Name on Card:

____________________________________

Check this box if you would like to find out more about
special methods of giving.

Comments:
______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________