DONATION FORM
Lopez Community Land Trust

Credit Card Donations:
I would like to put the donation on VISA/MasterCard.
Name on card: __________________________________________________________

Card #: _________________________________________Expiration Date: _________(mm/yy)

Amount: $___________

Signature: ______________________________________________________________

Donation Details:
How would you like your donation or tribute to be acknowledged in printed materials?

__________________________________________________   ______Do not use my name. 

Please send me LCLT’s newsletters via   ______Email   or   ______USPS mail.

______ Please send me a receipt. 

The Lopez Community Land Trust is a 501(c)3 organization. Federal Tax ID #: 91-1469975

My Address:
Street:________________________________________________________________________

City:_____________________________________  State:________ Zip: __________________

Email:________________________________________________ Phone:__________________

Please return to:
Lopez Community Land Trust, P.O. Box 25, Lopez Island, WA, 98261
Phone: (360)468-3723  Fax: (360) 468-3724  Email: lclt@rockisland.com