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Prowers Medical Center

A Star is Born

Only one star can be ordered per order form.
You may also contact the Foundation office at 719-336-7065.
  Donor's Name
  Address
  City
  State
  Zip
  Telephone
  I would like to purchase the following $50 - 4" Star is Born
$75 - 6" Star is Born
  Please Charge to Visa
Master Card
Discover
  Account Number
  Expiration Date:
You may also contact the Foundation office at 719-336-7065
Information to be engraved
4 Star Maximum of 2 lines, 1st line 24 characters 2nd line 20 characters, and spaces and punctuation are considered characters. 6 Star Maximum of 5 lines 1st line 30 characters 2nd line 20 characters, the 3rd, 4th and 5th 25 characters, spaces and punctuation are considered characters.
PLEASE PRINT CLEARLY
  Line 1
  Line 2
Lines 3 - 5
lines 3 5 are available in addition to 1 and 2 on the 6 star only
  Line 3
  Line 4
  Line 5
  Please send acknowledgement of my gift to:
  Name
  Address
  City
  State
  Zip
For questions/additional information, please contact the Foundation office Monday through Friday 8:00 a.m. to 5:00 p.m. at 719-336-7065 or foundation@prowersmedical.com