The Harold Leever Regional Cancer Center
1075 Chase Parkway
Waterbury, Connecticut 06708
voice 203-575-5555  fax 203-575-5556

I/We wish to make a gift of: 

$__________ or __$5,000  __$2,500  __$1,000  __$500  __$100  __$50  __$25

Enclosed is my check in the amount of $_______ payable to The Harold Leever Regional Cancer Center

Please charge my:
MC   VISA  Card Number ________________________________ Expiration Date __________________
                      
			Signature _________________________________________________

I/We would like my/our gift payable over _______ years.


Please bill the balance   Monthly   Quarterly   Semi-Annually   Annually

Please acknowledge my donation as a gift from:

Name(s) _________________________________________________________________________

Address _________________________________________________________________________

In memory of _____________________________________________________________________

The Harold Leever Regional Cancer Center
1075 Chase Parkway
Waterbury, CT 06708
Voice 203-575-5555
Fax 203-575-5556