I would like to make a contribution in the amount of:

___ $15   ___ $25   ___ $50   ___ $75    ___ $100   ___ $250   ___ $500    ___ Other

___Check/Money Order        ___MasterCard        ___Visa        ___American Express

Account No.____________________________________________ Exp. Date__________

Security Code_______________ (Last 3 or 4 numbers on the back of your card following the account #)

Signature_________________________________________________________________

Please Print:

____________________________________________________________________
Name (Mr., Mrs., Ms.)
 

_____________________________________________________________________
Company Name (if applicable)
 

______________________________________________________________________
Street Address                                                                                                   Apt.
 

______________________________________________________________________
City                                                                                          State                  Zip
 

______________________________________ _______________________________
Day Phone                                                                Evening Phone

E-Mail__________________________________________________

I am enclosing a check___________________ [number] with this form.
 
My Company____________________________ [name] has a matching gift program and

                  I am enclosing their matching gift form. _________ [yes/no]
 

I have special intentions for which I ask the Little Sisters to pray:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________
 
To make a credit card donation over the telephone please call 212-289-4014. 

Your statement will note that you made a donation to the Little Sisters through Paypal.

Please complete and mail to:

                                            Sr. Annette Allain, Provincial
                                            Little Sisters of the Assumption
                                            475 East 115 Street, 1st Fl.
                                            New York, NY 10029


                                            (212) 289-4014 phone                                            
                                            (212) 876-2075 fax
                                            Email: srannette@littlesisters.org

                           Thank You and may God Bless you for your generosity.