Rocinante Donor Form

Donation Form

Print this Out and Mail or Fax

To:
Rocinante
Box 41
Summertown TN
38483 USA
Tel: 615-964-2519
Fax: 615-964-2519
From:
Name:
Address:
City/State/Code:
Country:
Tel:
Fax:

I would like to make a tax-deductible donation to the Farm midwives. I understand I will receive a receipt by mail.

**Donor Categories**
ˆ	Category	Amount
	Donor	$1 - $499
	Contributor	$500 - $2,500
	Sponsor	$2,501 - $5,000
	Supporter	$5,001 - $10,000
	Sustainer	$10,001 - $25,000
	Benefactor	$25,001 and over

Amount Enclosed : ___________________

Please charge my VISA or MASTERCARD

Number: ______ ______ ______ ______ Expires: __________

Signature: __________________________________

A [sizable audio] word of thanks from Stephen Gaskin

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