Name:  ______________________________________________________________________________________________

Address:  ____________________________________________________________________________________________

City:   ________________________________ State:  ___________ Zip:  ________________________________________

Home Phone:  _______________________________________________________________________________________

Work Phone:  ________________________________________________________________________________________

Cell Phone:  _________________________________________________________________________________________

Yes!  I would like to contribute to the Heritage Initiative

P. O. Box 8039  •  Statesboro  •  Georgia  •  30460

Georgia Southern Botanical Garden

Amount $___________________           ___ check # ______     

    

_{CREDIT CARD}:  ___MasterCard    ___Visa    ___American Express  ___Discover

 

Account Number: ________________________________________________________________________

 

Date of Expiration: _______________________________________________________________________

 

Name printed on card: ____________________________________________________________________

 

Signature of cardholder: x _________________________________