Thank you and God bless you!

Name: __________________________________________________________ Address: _________________________________________________________ City: _________________________________________ State: ______________ Zip: _____________________ Phone: (________) ________________________ Email address: _____________________________________________________ MOTHER’S NAME: First name:

Last name:

(optional)

MY ROSE OFFERING: ($7.00 per rose)  Yellow Rose(s) – Quantity:

 Red Rose(s) – Quantity: ______

 Pink Rose(s) – Quantity:   Total Number of Roses: _____ _

 White Rose(s) – Quantity: ______  Total Offering Amount: $ ______

  My Check made out to America Need Fatima is enclosed.  No, I prefer to use my Credit Card: Credit card number: _______________________________________ Credit card expiration: Month Card type:

Year

 Visa

 American Express

 MasterCard

 Discover

Account Holder’s Signature REQUIRED Signature: _____________________________________ Date: _____________

WEBMCR18

Thank you and God bless you!

America Needs Fatima P.O. Box 341 Hanover, PA 17331 America Needs Fatima is a special campaign of The Foundation for a Christian Civilization, Inc., a 501 (C)3 corporation. All contributions to ANF are tax-deductible.