1610 N. Park St. Brenham, TX 77833 Phone: 979-203-7159 Email: info@supportourservants.org
Name:_________________________________________ Company:______________________________________ (if applicable) Mailing Address:__________________________________________ City:______________________State:_______Zip Code:__________ Phone:_________________________________________ E-mail:_________________________________________
PLEASE SELECT YOUR CHOICE OF SUPPORT
 Regular Supporter - $100 annually Platinum Supporter - $1,000 annually Quarterly Platinum Supporter - $250 quarterly (after completing $1,000 in donations, you will become a platinum supporter)  Business Supporter - $150 annually Business Platinum Supporter - $1,500 annually
Is this a renewal? Yes No
PLEASE RETURN COMPLETED APPLICATION WITH CHECK ( MADE PAYABLE TO: SUPPORT OUR SERVANTS), OR CREDIT CARD INFORMATION TO THE ADDRESS PROVIDED ABOVE.
American Express MasterCard Visa Discover Account Number: __________________________________________________ Credit Card Expiration Date: ___________________
THANK YOU