West Maui Improvement Foundation

Please print and mail this form with your contribution to:

WEST MAUI IMPROVEMENT FOUNDATION

501 (C ) (3) Non - Profit
IRS FED IDENTIFICATION No: EIN 99-0275775

P.O. BOX 10338
LAHAINA, HI 96761

$________________= (Contributing Friend)
$101.00-$250.00 = (Silver Contributor)
$251-$500.00 (Gold Contributor)
$501=$750.00 (Platinum Contributor)
$751.00-1,000.00 (Double Platinum Contributor)
$1,001-$2,000.00 (Charter Hospital Memorial Plaque-Friend)
$2,001-$3,000.00 = (Charter Hospital Memorial Plaque-Donor)
3,001-$4,000.00 = (Charter Hospital Memorial Plaque-Sponsor)
$4,001-$5,000.00 = (Charter Hospital Memorial Plaque-SilverGold Sponsor)
$5,001-$10,000.00= (Charter Hospital Memorial Plaque- Gold Sponsor)
$10,001.00-$20,000.00 = (Charter Hospital Memorial Plaque-Platinum Sponsor)
$20,001 + = (Charter Hospital Memorial Plaque - Lifetime Honor Roll Founder)

Credit Cards are accepted with complete information below:

1. *Name of cardholder: _______________________________________________________
2. Card number: ________________________________ 3. Expiration Date: ___________
4. *Billing Address: ______________________________________________________________
	______________________________________________________________
	_______________________________ 5. *Postal Code: ___________
6. Daytime Telephone: _____________________________
7. FAX: ______________________________
8. Email: __________________________________
9. *Signature as appearing on credit card:
_______________________________________________________________

(* = Required Information )

Please send in your donations today! A letter of acknowledgement and receipt from the tax deductible 501(c)(3) West Maui Improvement Foundation will be sent to you at the address on your check or other address you may prefer as follows:

______________________________________________________________________

Mahalo for making a positive difference!

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