I have made an online donation and wish to dedicate it.

(1) The information I gave when making my credit card donation was

Donations must be verified by us

*(Indicates a field which must be filled in)

My Name*

My Address*

Please

Include your

Postcode

# Must be filled if different to above, so we can verify that a donation has been made

# Name/s

On Credit card

Credit card owners

# Address

My Phone no

My Email*

(2)

I dedicate my donation to the Memory of

Name*

Who lived at

Relationship

To myself

(e.g. father, mother , aunty, close friend ,work colleague )

Who was at / used these Harlington Hospice Services

(If any)

(3) Optional

I would also like you to send a letter acknowledging my donation in Memory to: -

(e.g.  to deceased’s spouse )

(Leave below blank if you do not require this service)

Name

Address

Please

Include

Postcode

Relationship

To myself

(Between yourself and the recipient of the letter e.g. father, mother, aunty, close friend, work colleague)

Reason

(Expression of sympathy, anniversary of death, donation in lieu of flowers) 

Expressing These

Thoughts

(Your message to the recipient e.g. I will miss him greatly, my thoughts are with you)

Please Select......................... I do not want you to disclose the amount of money that I have donated I do want you to disclose the amount of money that I have donated

I [do]/[do not] want you to disclose the amount of money that I have donated to the recipient of the letter

(4) Optional

Any other instruction requests

(e.g. do not sent the letter until the funeral has taken place on the [ date] )

We will within our powers, to the best of our ability, carry out any reasonable instructions

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