The mission of the Mountain Valley Medical Clinic is to provide prompt high-quality medical care to the residents and visitors of Southern Vermont without regard to their ability to pay

The Mountain Valley Medical Clinic, one of the last independent, full-service clinics in Vermont, provides the highest quality primary health care to residents of the rural communities which it serves. Your support assures the success and
continuation of our non-profit facility.

Your contribution is tax deductible to the full extent allowed by law 501(C)(3) TIN 03?0240165

Name ________________________________________________________________________

Address _______________________________________________________________________

City ______________________________State ___________________ Zip __________________

Telephone ___________________ Email (for MVMC use only)_____________________________

Amount of Gift $_____________ Check Enclosed___

Please make your check to Mountain Valley Medical Clinic      or      M/C___   Visa___

Card # __________________ Expiration Date _____ Signature ___________________________

__ Request Matching Gift form  __ I am interested in including MVMC in my Estate planning

We plan to publish our honor roll of contributors. Would you like your name included? ___________

Please print how you would like your name to appear: _______________________________________

THANK YOU FOR YOUR GENEROUS SUPPORT!