Please print this page, clearly fill in the information and mail to:

Name:_________________________________________________

Company:______________________________________________

Address:_______________________________________________

City, State, Zip:_________________________________________

Phone Number:_________________________________________

Fax Number:__________________

E-mail:_______________________

Enclosed is my total contribution of $ _____________
(Please make checks payable to CASA of Hidalgo County)

Special Instructions:
This gift is in honor of:____________________________________

This gift is in memory of:__________________________________

An acknowledgment of this gift should be mailed to:

_____________________________________________________

_____________________________________________________