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Partnership for a Healthier Alexandria Donation Opportunities

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Name & Address of Person Making Payment

First Name*: Last Name*: Suffix:(MD, Sr., etc)
Address*:     Apt. No.:
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Daytime Telephone No.*:   -     Ext.:
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Please designate how to apply your donation:
Partnership for a Healthier Alexandria
OR one of its work groups:
Alexandria Clean and Smoke Free Air Coalition
Alexandria Childhood Obesity Action Network
Mayor's Get Healthy Alexandria!
Mental Health Anti-Stigma HOPE Campaign
Substance Abuse Prevention Coalition of Alexandria
$   Donation Amount

Bank Information

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Select Checking or Savings Account: Checking     Savings

I understand that all contributions are tax deductible to the extent allowed by the law. The City of Alexandria adheres to state and federal privacy laws to protect customer information. All payment information will be treated as confidential, and will only be shared with third parties to the extent required to complete the transaction, to collect a debt, or as otherwise required by law. This transaction is also subject to the City of Alexandria's web site Legal Notices. For more information about the eChecks service, please contact the City of Alexandria Treasury Division, 301 King Street, Suite 1510, Alexandria, VA 22314, 703.838.4777,

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NO, please cancel this payment.