C89.5

(1) Choose your donation

$ per month — Different Amount: $

Total annual pledge of $ to be paid with monthly credit card charges of $, automatically renewing yearly

First Name Last Name Address Line 1 Address Line 2 City State/Province Postal Code Country Phone Email

Card Type
Card Number Card Expiration

Bank Account Type
Bank Account Number

Routing Number

For collection of payment, an invoice will be mailed to the billing address provided.

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$ per month — Size —

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