LIGHT UP A LIFE
(Please fill out the form in capital letters)
Name: ..............................................................................
Address: .......................................................................... .......................................................................................... ..........................................................................................
Postcode: ........................................................................
Tel no: ...............................................................................
Email address: ................................................................ ...........................................................................................
In memory of: (full name) .............................................
...........................................................................................
My message: (eg ‘Thinking of you’) ............................ ...........................................................................................
........................................................................................... Remembered by: (your name as you’d like it to
appear) ............................................................................. ...........................................................................................
■■ If you would like to make more than one entry, please attach another sheet of paper in the same format as above.
Suggested donation (please circle):
£10 £20 £30 £50
Other: £ ............................................................................
(If paying by cheque, make payable to ‘City Hospice’)
Credit/Debit Card No: ................................................... ...........................................................................................
Expiry Date: ....................................................................
Issue Date: ......................................................................
Security Number: ........................................................... (We’re sorry but we don’t accept American Express)