Name_________________________________________ 

Address_______________________________________ 

City ____________________State ____ Zip__________

Email_________________________________________ 

Phone_____________________________________ 

Credit Card Number_____________________________ 

Expiration Date_________________________________ 

_________VISA    ______MasterCard    ____Am. Express 

Amount: $_____________________________________ 

Signature_____________________________________ 

In Honor of:____________________________________ 

In Memory of:__________________________________ 

Address for recognition of memorial or honorarium: 

Address_______________________________________ 

City ____________________State ____ Zip_________

CERFT is classified as non-profit 501c(3) organization, with all donations tax-deductible to the extent allowed under existing law.

Please complete this form and fax to: 817-759-7030