Clearfield Jefferson Suicide Prevention Team

The First Annual Walk for Suicide Prevention and Awareness

Business Donor Information (please print or type)

Name of Business

Contact Person

Address

City, State, Zip

Business Phone Number

E-Mail

Pledge Information

Please Circle One: $100 $150 $200 $300 $500

**If dollar amount differs from list, please write in amount below.**

I (we) pledge a total of $ _______________.

I (we) plan to make this contribution in the form of:
cash check (check number) _________

Acknowledgement Information

Please use the following name(s) in all acknowledgements:

Please make checks or other gifts payable to:

Clearfield Jefferson MH/MR Suicide Prevention Team

PO Box 344, DuBois, Pa. 15801

*A receipt will be sent to you once your donation has been received.*

Thank you for your generous contribution.

Any questions can be directed to:

Mary Brown, Suicide Prevention Team Coordinator

Phone: 814-265-1060 x330

Cell: 814-603-1107