Information Request Form

I would like:
	A complimentary subscription to the KCRM Connection Newsletter
	Monthly email updates of Mission Happenings
	A tour of the KCRM facility
	A KCRM representative to speak at my church or group
	Information about including the Kansas City Rescue Mission in my will or estate plans
	Information about making an in-kind donation (non-cash gifts and other donations)
	Help with starting an Alcoholics Victorious (Christ-centered AA) group
	A referral for someone in need
	Prayer for:
	Other:
Name: Address 1: Address 2: City: State:  Select State Alabama Alaska Alberta Arkansas Arizona British Columbia California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory Ontario Zip: Phone: Cell: Fax: E-mail:            Preferred Method of Response: Select One Mail Phone Cell Fax E-mail Not Applicable Best Time to Reach Me:

Information you provide on this form is for internal purposes only. It is kept confidential.