Floyd Healthcare FoundationPlease print out, complete, and mail this form with your check or money order to: Floyd
Healthcare Foundation Thank you for your support! Name _______________________________________________________________ Street _______________________________________________________________ City ___________________________________ State _____ Zip ________________ Telephone ______________________ E-mail
_________________________________ Amount Donated ________________________________________________________ Please check here if:
_____ I prefer not to be listed publicly as a Floyd Healthcare Foundation Supporter
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