Please PRINT THIS FORM and mail it in with your donation.

Make checks payable to:
HALE MAKUA

and mail to:

Maui Long Term Care Partnership
472 Kaulana Street
Kahului, Maui, Hawaii  96732

Name____________________________________________________________ 

Mailing Address:___________________________________________________

City: _____________________________

State _______________________________   Zip Code__________

Phone: _____________________________________________  

Fax:  _______________________________________________

E-mail: _____________________________________________

Amount of Contribution:________________________________

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