Please
print this form and fill in the following information.
and families, providing clean water, food, housing and education.Mail the completed form to: Reiser Relief, Inc. P.O. BOX 48096 Coon Rapids, MN 55448
A mission to help the
impoverished people of Haiti with a focus
children
Name:___________________________________________________________ Address:_________________________________________________________ Apt:_______ City____________________________________ Sate:___________ Zip:______________ Phone:__________________________________ Email:__________________________________________ Payment Information: Please check appropriately and enter your credit card information. I have enclosed: Cash:___ Check:___ Amount of Donation:$___________ Card Type: Visa:___ Master Card:___ American Express:___ Card #__________________________________________________________ Expiration Date:______________________ CVV2:____________________ CVV2 is a 3-digit number at the end of the credit card number on the signature panel on the back of the credit card, and 4 digits on the front of an American Express card Thank You for your gift!
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