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Amount Information
Amount
$ 1,000.00
$ 500.00
$ 250.00
$ 100.00
$ 50.00
$ 25.00
Other
$
*
Donation Information
TYPE OF GIFT:
One-time gift
Recurring gift
Frequency:
Weekly
Monthly
Quarterly
Annually
On:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Starting:
Ending:
Ending:
Corporate:
This donation is on behalf of a company
ANONYMOUS:
I prefer to make this donation anonymously
COMMENTS:
Billing Information
TITLE:
Mr.
Ms.
Mrs.
Dr.
Miss
FIRST NAME:
*
LAST NAME:
*
COUNTRY:
United States
*
ADDRESS LINES:
*
CITY:
*
STATE:
<Please Select>
NO
NSW
SA
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
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CZ
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DE
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FM
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IA
ID
IL
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MB
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ME
MH
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MO
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ON
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NU
*
ZIP:
*
PHONE:
EMAIL:
*
Payment Information
PAYMENT METHOD:
Credit Card
Direct Debit
CARDHOLDER'S NAME:
*
CREDIT CARD NUMBER:
*
CARD TYPE:
Visa
American Express
Discover
MasterCard
*
CARD EXPIRATION:
01
02
03
04
05
06
07
08
09
10
11
12
/
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
*
CARD SECURITY CODE:
*
My gift is a tribute to someone special (optional):
TRIBUTE TYPE:
in honor of
in memory of
in recognition of
*
Name:
*
TRIBUTE FIRST NAME:
TRIBUTE LAST NAME:
*
Yes, please notify the honoree(s) that a gift has been made in their honor (to assist our office in notifying the honoree(s), please provide any contact information; if unknown, leave blank).
*
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Phone: 952-974-9600 | Email:
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