Medallion Program

Name:

Email:

Mailing Address:

City, State, Zip:

Phone or Fax:

I would like to purchase a Medallion in the:

Prime Location

[1st Choice] A B C D [2nd Choice] A B C D

Average Location

[1st Choice] E F G H I [2nd Choice] E F G H I

INSCRIPTION (up to 20 characters per line, including spaces):

First Line:

Second Line:

Enclosed is my Ck# in the amount of $

Stop here, print out form, and mail with your check to:
Alameda County Health Care Foundation
Medallion Program
1411 East 31st Street
Oakland, CA 94602

OR
I would like to pay by credit card.
(Submit this form, using the SUBMIT button below, then go to Donate Online.)

OR
Please arrange for a direct deposit/payment. (If you check this option, someone will call you to make the arrangements. Please be sure to include your daytime phone number above.)