Franklin County Volunteers in Medicine Clinic

Donation Form

Join FCVIMC in its efforts to alleviate the effects of poverty in our communities. With your support, we can make a difference in the lives of many families and individuals who live in poverty.

I would like to make a tax-deductible contribution to FCVIMC.

My gift of $__________ is enclosed.

Name:
    _________________________________

Organization:
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Address:
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City:
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State/Zip:
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Home Phone:
    (_____) __________________________

Work Phone:
    (_____) __________________________

Fax:
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E-mail:
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Thank you for your support!

Donate!

Print out this form and fax or mail it to:

Franklin County Volunteers in Medicine Clinic
109 N. Church St
Louisburg,  NC 27549

Call: (919) 496-0495
Fax: (919) 496-0493

You can also make your secure donation online
through Paypal:

Most donations are tax-deductible.