Name or Organization: _______________________________________________________________

                             _______________________________________________________________


Address:__________________________________________________________________________


City:_______________________________________    State:__________        Zip:_______________


Telephone:___________________________________


Fax: ________________________________________


Email:_______________________________________


Please accept my gift in the amount of

                                  ____ $1,000

                                  ____ $500

                                  ____ $250

                                  ____ $100

                                  ____ $50

                                  ____ $_________

Enclosed is my check payable to : The Agape House




Thank You for your Donation to The Agape House


Please mail to:
The Agape House
222 N. Carrollton Avenue
Baltimore, MD 21223