Contributor Information

You may complete the form and mail it with your check or money order payable to Gateway Rehabilitation Center to:

                        Development Department
                        Gateway Rehabilitation Center
                        100 Moffett Run Road
                        Aliquippa, PA  15001

Please provide the following contact information:

Name
Title
Address
City
State
ZIP
Work Phone
E-mail

Amount of Gift:

If Other:

Method of Payment:

Check here if a check or money order in enclosed:

Name as it appears on the card:

Account Number:

Expiration Date

Please apply my gift toward:

If other:

This gift is being made:

Name:

Name and Address of Person to Notify of Gift:


For more information please contact the Development Department at 800.472.1177, ext. 1235. Thank you for your generosity.

                “The official registration and financial information of Gateway Rehabilitation Center may be obtained from Gateway (800.472.1177) or from the Pennsylvania Department of State by calling toll free, within Pennsylvania, 800.732.0999.  Registration does not imply endorsement.”