Secure Donation Form

To process your donation using Visa, MasterCard, American Express, or Discover, please fill in the secure order form below with the requested information exactly as it appears on your monthly bankcard statement.
 

Billing Information - Exactly as it appears on your Credit Card

Donor Prefix:
Donor First Name:  *
Donor Middle Initial:
Donor Last Name:  *
Suffix (eg: Jr,Sr,II):
Billing Address:  *
Apartment or Suite:
Billing City:  *
Billing State or Province:  *
Billing Postal/Zip Code:  *
Billing Country:  *
Day Time Phone Number:
Mobile Phone Number:
Credit Card#:  *
Expiration Date:  *
Card Verification Value:   *
E-Mail Address:  *
Email to added to our list
 

Donation Information

Please Choose Donation Amount Here 20 Dollars - $20.00
25 Dollars - $25.00
30 Dollars - $30.00
35 Dollars - $35.00
50 Dollars - $50.00
100 Dollars - $100.00
250 Dollars - $250.00
500 Dollars - $500.00
750 Dollars - $750.00
Tribute Type:
Comments Here
   Maximum of 210 Characters
Characters not allowed: %, &, #, <,>
 
* = Required Field

This transaction is being processed by Lake Zurich Rotary Club using Secure Socket Layer (SSL) Encryption.