The purpose of the West Hollywood Recovery Center is to provide assistance with addiction recovery, prevention and education to those in need. Your contribution is greatly appreciated and is tax deductible.
                        WHRC is a 501(c)3 non-profit organization.
                           Our tax identification # is: 04-3614548

Donor #1
Donor #2 (If you wish to be acknowledged as a couple)
City / State / Zip
Email Address
Payment Options:      All at once      Quarterly      Monthly
Donors choosing to fulfill their pledge quarterly or monthly are requested to provide credit card information so we may process your pledge in a timely manner.
Payment Type:   Check Enclosed     Charge My: Visa     Mastercard
Card Number
Exp Date
Name on Card
Billing Address (if different from above)
For donors making their pledge by credit card and/or by quarterly or monthly payments please fill in the amount of your pledge, date and sign the following:
My signature hereby acknowledges the amount of $___________as an annual commitment to WHRC beginning on ___________ and ending one year from that date.

Today's Date:________________________ Signature:_______________________________
Please return this form with your payment to:
West Hollywood Recovery Center
8391 Beverly Boulevard # 345
Los Angeles, CA 90048

_________________________________________________________________ Office use only.