Verland's Direct Support Professionals Donation Form

Complete and to mail or fax this form to donate directly to Verland or click SUBMIT to contact us via email.

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How did you hear of Verland?	Direct Support Professionals cash donation Website Word of mouth Article Staff Mail Electronic mail Event Other TV	E-mail Address
Salutation Daytime Telephone Number	Mr. Mrs. Ms. Dr. Required	First Name Last Name	Required Required
Home Address
Address (cont.)		Organization
City
State/Province
Zip/Postal Code
Type of Gift:	Direct Support Professionals cash donation Money Adopt a Horse Art Furniture Office Equipment Computer Equipment Building Land Vehicle Household item(s) Bequest Stock Insurance policy Will Trust Other
Amount of Gift:

THANK YOU FOR YOUR CONTRIBUTION. Please provide any additional information you feel will be helpful.

Select any of the following options that apply:

	Credit Card Credit Card Company: Number Expiration Date Signature:
Call us at 412-741-2578 to provide credit card information

To send via United States mail , via fax to (412) 741-2350 or for credit card authorization,
please print, sign and mail this form to Verland.

Click below to submit to Verland via email.