Home Health and Hospice Care “Completing the Circle of Care” 2402 Wayne Memorial Drive Goldsboro, NC 27534 Phone 919-735-1387 Fax 919-735-8460

"Tree of Life" Leaf Order Form

Your Home Address: Name: _______________________________________ Company Name: _______________________________ Address: _____________________________________ City, State, Zip: ________________________________ Phone: ______________________________________

Leaf #	DEDICATION (no more than 3 lines of text, 25 characters per line, please)		UNIT PRICE	TOTAL
1			$100.00
2			$100.00
		SUBTOTAL
		TOTAL

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1. Please remember to enclose your payment with your order. 2. Please allow two to three weeks for delivery. 3. Send all correspondence to: Community Development Coordinator c/o 3HC - Tree of Life 2402 Wayne Memorial Drive Goldsboro, NC 27534 Phone: 919-735-1387	Payment Method: ___ I am enclosing a check or money order with my order. ___ Please charge to my (circle one) Visa,       MasterCard,               American Express: Account Number: _________________________________ Expiration Date: __________________________________
	Signature Date

Thank you for your support of 3HC's Hospice Program.

3HC is a 501(c)(3) agency and all donations are

tax deductible as allowed by IRS regulations.