Method of Payment

__ Enclosed is my check made payable to FOCUS in the amount of $________.

__ Please charge my credit card account using the information provided below:

Amount to charge $_______ Date ______
Card Type __AmEx __VISA __Mastercard __ Discover
Card # ______-_________-__________-________
Exp Date (mm/yy) _____/____
Last three digits on signature line _______

Signature: _________________________________

Your Information

Name _____________________________________
Address ___________________________________
City__________________ State _____ Zip _______
Phone ________________ Fax _________________
E-Mail ____________________________________

This gift is made in memory of ___________________

This gift is made in honor of _____________________

This gift is made in honor of the occasion of
__ birthday __ marriage __ recovery from illness
__ engagement __ anniversary __ new baby
__ confirmation__ baptism __ graduation
__ bar/bat mitzvah __ other

Please notify:

Name _________________________________________________________________
Address ______________________________________________________
City__________________ State _____ Zip _______

From _________________________________________________________________
(your name as you want it to appear)

(If you would like a second notification, please write that information below)

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