Name ___________________________
Address _________________________
City _____________________________
State ______________ Zip __________
Phone ___________________________
Amount Enclosed $_______________
Individual $25
Family $40
Non-profit Organization $40
Small Business $50
Friend $50 - $99
Contributor $100 - $249
Donor $250 or more
___ Check enclosed ___ MasterCard ___ American Express
___ VISA ___ Discover
Name on Card __________________________________________________
Card Number
___________________________________________________
Expiration Date ____________
V-Code ___________________
Amount to be charged _______________
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