Postal Mail Order Form       

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Send your donation to  The Life Center  

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Make your check or money order payable to The Life Center 

Mail to:

Rev. Robert Cote'

The Life Center  

11589 La Grange Rd.

Jamestown CA  95327

                                          Please print Clearly

Your Name:_______________________________________________

Mailing Address:___________________________________________

City:_____________________ State:__________  Zip:___________

E-mail Address:  __________________________________________

Phone Number:  ___________________________________________

Whom do you know that we should contact regarding our work?

Their Name:______________________________________________

Mailing Address: __________________________________________

City:_____________________ State:___________ Zip:__________

Their E-mail Address: ______________________________________

Can we say that you referred them to us  _____ YES  _____ NO.

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Please share your thoughts and opinions with us.

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