Donation Mail/Fax Form

Directions   1. Print this form from your browser. 2. Fill in your contact information, ensuring that all required fields (indicated by '*') are completed. The name entered will be the name credited for the donation. 3. Complete the applicable payment section entirely. 4a. For check donations, mail the completed form (along with check or money order) to the address shown below. 4b. For credit card donations, mail or fax the completed form to the Smart Start of Brunswick County  . Smart Start of Brunswick County PO Box 3050 Shallotte, NC 28459 ph (910) 754-3166 fax: (910) 754-3188

Contact Information Name * Address Phone * E-mail Subscribe ( ) I would like to receive the Smart Start of Brunswick County  e-mail newsletter. ( ) Do not send me e-mail.

Pay By Check Check No. Donation Amount Name on Check

Pay By Credit Card Donation Amount Card Owner Card Type Circle One: MasterCard Visa Card Number Exp. Date