MISSISSIPPI ACADEMY OF FAMILY PHYSICIANS FOUNDATION
All gifts made payable to the MAFP Foundation are tax deductible to the extent allowed by law.
 
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone:
Email:
   
One Time Gift Amount: $
   
Recurring Gift Amount: $
  I would like to become a "FOUNDATION FRIEND" by being a monthly donor. Please set up a monthly credit card gift to begin on (date), that will continue until I notify otherwise. (Payment will be charged on the 15th of each month and can be cancelled with a 30-day notice).
   
The gift is in: Honor or Memory of:
   
Please notify the following person of this gift:
Name:
Address:
City:
State:
Zip:
   
I have made provisions for the MS Academy of Family Physicians Foundation in my will.
I am interested in the Planned Giving Program. Please have someone from the Create Foundation contact me.
  Legacy League Bequests Charitable Trusts
  Retirement Plan Gifts Life Insurance  
   
Payment Information:
Credit Card Type:
Credit Card Number:
Cardholder Name:
  (Type name exactly as it appears on credit card)
Card Expiration Date:
Card Verification Code:
  (3 or 4 digit number on the back of the card or on the front of the AMEX card)
Address:
City:
State:
Zip:
   
   
For more information contact: MAFP Foundation, Kim Erickson, 133 Executive Drive, Suite E, Madison, MS 39110, Office (601)853-3302, Cell (601)941-2152, Fax (601)853-3002 or email kim@msafp.org.