Please print out, complete, and mail this form with your check or money order to:

The Foundation of FirstHealth
150 Applecross Road
Pinehurst, NC 28374

If you would like to use a credit card, please enter the information on the spaces below.

Thank you for your support!

Name _________________________________________________________________

Street ________________________________________________________________

City ___________________________________ State _____ Zip ________________

Telephone ______________________

E-mail _________________________________
          (must have if electing to receive Donor E-mail)

Amount Donated ________________________________________________________

For credit cards (MC, VISA, DISCOVER)

Type of card ___________ Account Number___________________________________

Expiration date ______________ Signature ___________________________________

Please check here if:

_____ I prefer not to be listed publicly as a FirstHealth Supporter
_____ I prefer not to receive the quarterly Donor E-Mail