Special Request Mail Form

Please fill out this form, print and mail it with payment to:

Support & Donations
Daughters of Charity Emmitsburg Province, Box 1633
333 South Seton Avenue
Emmitsburg, MD 21727-9297 USA

or call 301.447.6976

*required information

Focus of Prayer Request: Recovery from illness
Return to the sacraments
Peace in the home
Civic and world peace
Security in employment
Thanksgiving for a favor
Deceased family members
Peace of mind
Other
Person requesting prayers: *
Email:
Phone: *
Address:
 *
City:
 *
State or Country:
*
Zip Code:
 *
   
What is the nature of your request (choose one and enter name or occasion)?
In memory of: *
In honor of:
Enter special
intentions
or comments:
Number of Cards to send you: *
Donation amount:
Other amount:
   
Name:
Address:
    
City:
    
State:
    
Zip Code :
   
Phone:
    
Email:
    
Payment Information
Check enclosed
Credit Card Payment
VISA      Mastercard
Card Number
Name on Card
Security Code
Exp date
 Signature
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