Heritage Ministries
Membership and Donation Form
 
Contact Information
First Name:  Last Name: 
Address: 
City:  State:  Zip:
Phone #:  Email: 
Do you wish to make a DONATION?   Yes  No
If yes, please complete the following information.
Donation Amount: $ 
If other, please explain:
Would you like to purchase a Membership?  Yes  No
Local Church
Information
Name: 
Pastor
Information
First:  Last: 
Phone #:  Email: 
Heritage Ministries Director
Information
First:  Last: 
Phone #:  Email: 
Additional Memberships
  How many memberships would you like to add?  

If you are adding additional memberships, please list the person's first name, last name, phone number, and email address separated by commas and followed by a semicolon.. (i.e., John Smith, 123-456-7890, johnsmith@email.com; Jane Smith, 123-456-7890, janesmith@email.com)
Payment Information
Card Type:
 
 Card #: 
(i.e. 1234-5678-9012-3456)

Expiration:
 
  

CVV:
  What's this? 
Annual Membership is $10.00 per person. Please add $10.00 per person plus any donation you would like to make to Heritage Ministries and confirm the amount to be charged to your card.

I understand my card will be charged $ .
Credit Card Billing Information
Cardholder: 
Address: 
City:  State: Zip: