Donor Prefix:
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Donor First Name:
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*
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Donor Middle Initial:
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Donor Last Name:
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*
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Suffix (eg: Jr,Sr,II):
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Billing Address:
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*
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Apartment or Suite:
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Billing City:
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*
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Billing State or Province:
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*
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Billing Postal/Zip Code:
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*
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Billing Country:
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*
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Day Time Phone Number:
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Mobile Phone Number:
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Credit Card#:
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*
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Expiration Date:
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*
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Card Verification Value:
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*
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E-Mail Address:
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*
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Donation Information
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For donations (Use Other)
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Technology and Software
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$10,000.00
Produce Display
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$5,000.00
25 Pallets Worth of Food
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$3,600.00
Volunteer Break Room Supplies
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$1,000.00
Refrigerators
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$500.00
Shopping Carts
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$180.00
Chairs
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$75.00
Hygiene Supplies
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$36.00
Box Cutters
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$18.00
Other:
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Tribute Type:
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Tribute Notification
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Notes
Maximum of 210 Characters
Characters not allowed: %, &, #, <,>
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* = Required Field
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