YOUR Name and Address ____________________________________

_________________________________________________________

City ___________________________State & Zip _________________

If you would like your gift to be given as a memorial to a particular individual,
Please complete the information below:

In Memory Of ____________________________________________

PLEASE SEND MEMORIAL CARD TO:

Name ____________________________________________________

Address __________________________________________________

City ____________________________ State & Zip ________________

PLEASE CONTACT ME WITH INFORMATION ABOUT:

Gifts From My Estate _____

Gift of stock or other non-monetary gift _____

Volunteer Opportunities _____

PLEASE MAIL THIS FORM WITH YOUR GIFT OR INQUIRY TO:

Hospice of North Central Oklahoma
1904 N. Union, Suite 103
Ponca City, Oklahoma 74601

If you need help in deciding about your gift, please call the Executive Director of
Hospice of North Central Oklahoma at: 580-762-9102

THANK YOU!