Thank you for supporting the activities of Chabad of the West Side! First Name Last Name Address City State Zip Phone Phone Type Home Work Cell Email address ________________________________________________________ Card Type MC Visa Amex Amount to charge $ Card Number Expiration Date 01 02 03 04 05 06 07 08 09 10 11 12 2015 2016 2017 2018 2019 2020 2021 2022 2023 IMPORTANT: Please choose the purpose for this contribution: General Donation Hachnasat Orchim Fund Kiddush Friendship Circle Kollel Other PLEASE NOTE: This form is for charitable contributions only. To make a payment for purchases or services, please click here. ______________________________________________________________ Optional: This donation is: For: Please specify below In honor of: In Memory of: Special Requests or comments: This page uses 128 bit SSL encryption to keep your data secure.