Home Health and Hospice Care, Inc.

“Completing the Circle of Care”

2402 Wayne Memorial Drive

Goldsboro, NC 27534

Phone 919-735-1387  Fax 919-735-8460

"Walk of Life" Order Form

Your Home Address:

Name: _________________________________________

Company Name:__________________________________

Address: _______________________________________

City, St, Zip: ___________________________________

Phone: _________________________________________

The stone should read:

Name: _________________________________________

Year of Birth:__________________________________

Year of Death: _______________________________________

Please circle one choice:

                 In Memory Of              In Honor Of

QTY

DESCRIPTION

UNIT PRICE

TOTAL

Walk of Life Stone

$250.00 

Additional donation to help fund Hospice Programs of 3HC

SUBTOTAL

TOTAL

$                    

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

2307-A Norwood Ave.

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