Make a Difference Donation Information Amount: $50.00 $100.00 $250.00 $500.00 Other $ * Designation: Where it is needed most Other Other * Additional Information Type of gift: One-time giftRecurring gift Frequency: Weekly Monthly Quarterly Annually On: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Starting: Ending: Ending: Comments: Spouse/Partner Full Name: Billing Information Title: Dr. Mr. Mrs. Ms. Ambassador Capt. Col. Fr. Lt Col Lt. Cmdr. Major Maj Gen Master Rabbi Representative Rev. Senator The Honorable The Reverend * First name: * Last name: * Country: Afghanistan Albania Algeria Argentina Aruba Australia Austria Bahamas Bahamas, B.W.I.-INACTIVE Bahrain Bangladesh Barbados, W.I. Belarus Belgium Bermuda Bolivia Brazil Bulgaria Canada Cape Verde Cayman Islands Chile China Colombia Congo Costa Rica Croatia Czech Republic Democratic People's Republic of Korea Democratic Socialist Republic of Sri Lanka Denmark Dominican Republic Ecuador Egypt El Salvador England Fiji Finland France Germany Ghana Grand Cayman, B.W.I. Greece Grenada Guatemala Guinea Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Ireland Israel Italy Jamaica Japan Jordan Kenya Kuwait Lebanon Lesotho Liechtenstein Luxembourg Macedonia Malaysia Maldives Malta Mexico Monaco Morocco Mozambique Nepal Netherlands Netherlands Antilles New Zealand Nicaragua Nigeria Northern Mariana Islands Norway Oman Pakistan Palau Panama Peru Philippines Poland Portugal Puerto Rico Qatar Republic of Cyprus Republic of Korea Republic of Zaire Romania Russia Rwanda Saint Lucia Saudi Arabia Scotland Senegal Singapore Slovenia South Africa South Korea Spain Sri Lanka Sudan Sweden Switzerland Taiwan Tanzania Thailand Trinidad and Tobago Turkey Ukraine United Arab Emirates United Kingdom of Great Britain and Northern Ireland United States Uruguay Venezuela Virgin Islands Wales Zambia Zimbabwe Address lines: * City: * State: <Please Select> AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA MA ME MD MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AB BC MB NB NL NT NS NU ON PE QC SK YT GU MP PR VI AS CZ FM MH PW AA AE AP ACT NSW QLD SA TAS VIC WAS NAT * ZIP: * Phone: Email: * Payment Information Cardholder's Name: * Credit Card Number: * Card Type: Visa American Express Discover MasterCard * Card Expiration: 01 02 03 04 05 06 07 08 09 10 11 12 / 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 * Card Security Code: * Tribute Information Type: in honor of in memory of * Name: * First name: Last name: * Mail a letter on my behalf * If you prefer to make your gift by check, please print out the printer-friendly version of this form, fill in the required information and send it to: Brigham and Women's Hospital Development Office 116 Huntington Ave. 3rd Floor Boston, MA 02116 Please make check payable to Brigham and Women's Hospital. The information you submit when making a credit card donation to BWH online is safe. To learn more, read our security statement. Brigham and Women's Hospital is a non-profit, 501c3 charitable institution. Your gift is tax-deductible to the extent the law allows.