"*" indicates required fields Use the form below to make a donation!Donor InformationWhat type of donation would you like to make?*---Cash donationGift or Basket DonationDonation Amount* $25.00 $50.00 $75.00 $100.00 Other Your Donation Amount* Total Name* First Last Business NameAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Credit Card Item Donation InformationItem Name*Item Value*Item Description (For Use in Auction Program)*Item Delivery Method Drop off / Mail to Bristol Village Have your item picked up by Bristol Village Drop off / Mailing Address: Bristol Village 8455 Clarence Center Road Clarence Center, NY 14032 Phone - 716-406-9500Is the item location / contact information different than the donor information? No Yes Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Donor Tax Information- In compliance with IRS requirements, we inform you that Bristol Village has not provided you with any goods or services in consideration for your gift. - Donations become the property of Bristol Village. - Valuation of donated property is responsibility of donor.I agree to the Terms and Conditions* I agree
