Please print out this form and mail to our office at:

P.O. Box 4284, Salisbury, NC 28145

Bride and Groom Names:
Amount of Donation:
Name(s) on Acknowledgment:
Method of Payment:
Check               Visa        Mastercard
Card Number:
Expiration Date:
Name as appears on card:
City: State: Zip:
email Address:

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