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*First Name:.......................................... *Last Name: .......................................................................... *Phone:

*Address: ............................................................................................................ *City:........................................................... *State:

*Zip: ............................................... * Email: ............................................... *Confirm Email:

*Card Type: ......................... *Card Number:....................................... *Exp: ....................... CVV:
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You may acknowledge my gift to my email address
Please acknowledge my gift by mail to the above street address.

Recurring donation:
Please charge the above amount to my credit card each month for the next twelve months.

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