Community Based Car

Donation Payment Form

Donation Summary:
Date: 12/14/17
Gift Type:
Donation Amount :
(Suggested amount $25.00,$50.00,$100.00,$250.00,$500.00, $1,000.00 or other)
Credit Card Information:
Card Type:

Name as on Card:
Card Billing Address:
Card Billing Zipcode:
Card Number:
Card Expiration Date: MMYY
Card ID (CVV2/CID) Number:
 
[What is the Card ID?]
   
Donor Information:
First Name:
Last Name:
Physical Street Address:
City:
State:
Phone Number:
Email Address:
Comments:
Yes, I'd prefer to remain anonymous
Yes, I'd like to receive emails from Community Based Care of Central Florida
To be matched by my employer
     


A COPY OF THE OFFICIAL REGISTRATION (CH36517) AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES AT www.800helpfla.com OR BY CALLING TOLL-FREE (800-435-7352) WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE.

If you would like to donate via check, you may mail your gift to:
Community Based Care of Central Florida
4001 Pelee Street
Orlando, FL 32817