1.
DONATION
FORM
I,
the
undersigned,
agree
to
donate
the
following
item
for
use
in
The
Cassie
Hines
Shoes
Cancer
Foundation’s
1st
Annual
Race
in
These
Shoes
on
August
12,
2012.
Please
state
exact
description,
including
size,
color,
services
provided,
dates
available,
number
of
persons,
days,
weeks,
nights,
and
restrictions,
where
applicable.
ONLY
ONE
ITEM
PER
DONATION
FORM.
Signature:
Brief
Description
of
Item:
Donor’s
Estimated
Value
of
Item:
$
Exchangeable
(circle
one):
Yes
No
I
wish
to
make
a
cash
donation
in
the
Gift
Certificate
Enclosed
(circle
one):
Yes
No
amount
of
$______________
(Make
check
payable
to:
The
Cassie
Hines
Shoes
Cancer
Foundation)
Expiration
Date
(if
any):
Any
Restrictions?
(circle
one)
Yes
No
If
applicable,
please
list
restrictions:
Donor’s
Name:
Company
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
E-­‐mail:
Recognize
Donor
Under
(circle
one):
Pump
Level
Slip-­‐On
Level
Loafer
Level
CHSCF
Representative
Name:
Donor:
Please
return
this
form
with
your
donation
to
the
CHSCF
Representative
listed
above
or
mail
to:
The
Cassie
Hines
Shoes
Cancer
Foundation
P.O.
Box
345
Washington,
MI
48094
Phone:
586.322.0991
Please
keep
a
copy
of
this
form
for
your
records.
The
Cassie
Hines
Shoes
Cancer
Foundation
is
an
IRS
recognized
501(c)3
organization
eligible
to
receive
contributions.
Your
contribution
may
be
tax
deductible
under
IRS
regulations.
All
Donors
will
receive
an
Acknowledgement
Letter
after
the
event.