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DONATION AMOUNT
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LAST NAMME
ADDRESS
CITY
STATE
ZIP
PHONE NUMBER
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I AGREE TO DONATE THE AMOUNT SPECIFIED
I AGREE THAT MY DONATION WILL HAPPEN AUTOMATICALLY FOR A MINIMUM OF 12 MONTHS
MY SECOND AND ALL FURTHER DONATIONS WILL BE FOR THE AMOUNT OF: (You will NOT be charged twice for this months donation)
MY DONATIONS WILL HAPPEN
WOULD YOU LIKE A RECEIPT FOR EACH RECURRING DONATION?
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CARD EXPIRATION DATE
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