VOTIVE LIGHT FORM

Fill out the form below, print and mail it to: The Association of the Miraculous Medal:

Dear Father,

Please light a Votive Light for my intentions at The National Shrine of Our Lady of the Miraculous Medal.

My Votive Light offering is $

(The usual offering for Votive Lights is: $10 for 60 days, $15 for 90 days, $25 for six months, and $50 for one year.)

I would also like to give a gift to the Association of the Miraculous Medal.
$25 $10 $100 $
Title:   Other:  (IVO8)
Name
Address Apt.
City
State:   Zip
Phone Number
Email Address

Are you on our mailing list? Yes No
If so, it would be helpful to give us the 9-digit number at the top of your mailing label

For your convenience we accept Visa, Discover, MasterCard, and American Express.
Card Number
Expiration Total Charge $
Name on card

Signature ____________________________

After you print this page, sign it and mail it along with your donation to:

Association of the Miraculous Medal
1811 West Saint Joseph Street
Perryville, MO 63775 USA

or fax it to the Association at 1-573-547-1389