Community Healthcare of Texas - Acceptiva

Select which Community Fund you want your gift designated to:

Your information for acknowledgment

Your Name:

Your name as you wish it to appear on ornament card.

Address:

City:

State:

Zip:

Email:

Phone Number:

(in case we have questions about your cards)

My "Gift of Light"

My "Gift of Light" #1 is:

(a minimum of $10 per gift, please)

Of:

Please notify the following person(s) that a gift of light has been made in honor/memory of their loved one:

Name:

Address:

City:

State:

Zip:

Payer Information

First Name: *

Last Name: *

Billing Address: *

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Email: *

A receipt will be e-mailed to this address.

Telephone:

Name on Card:

Card Number:

Security Code:

Expiration Date: