NSC MEMORIAL FORM

My/Our gift of $________________                              Your Name:_________________________________

is given in Honor of_______________________         Address:____________________________________

                                            (Please print)                      Give Address Below                                                                 

or in Memory of__________________________          City:_______________State:__________Zip:______

                                                        (Please print)

Send Memorial Card to:                                                                 Credit Card_________ #________________________________Exp_________

Address:_________________________________________           Signature_________________________________________________________

City:_________________State:____________Zip________

National Service Committee

 Chariscenter USA/P. O. Box 628

Locust Grove, VA 22508