Ometz Donate Online |
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I support Ometz with a donation of: | |
Other Amount | |
Make this a recurring transaction? | |
First Name | |
Last Name | |
Date of birth (not mandatory) | | / | | / | |
(Information provided for date of birth optional only to be used internally) |
E-mail | |
Phone | |
Address | |
Address 2 | |
City | |
Province | |
State | |
Postal Code/Zip | |
Comments | |
Cardholder's Name | |
Is this a Corporate Credit Card? | |
Organization/Company | |
Card Type | |
Credit Card Number | |
Expiry Date | | / | |
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Verification Number | The Verification Code is a three-digit number on the back of your Visa or Mastercard credit card |
Would you like to send a tribute card? | |
How would you like to send the tribute card? | |
Type of Gift: | |
Name of person being honoured or in whose memory the donation is being made: | |
Name of person to whom the Tribute card is destined: | |
Personal message to print in card: | |
First Name | |
Last Name | |
E-mail | |
Address 1 | |
Address 2 | |
City | |
Province | |
Postal Code/Zip | |
Country | |
Additional Card | |
Type of Gift: | |
Name of person being honoured or in whose memory the donation is being made: | |
Personal message to print in card: | |
Name of person to whom the card is destined: | |
How would you like to send the tribute card? (2nd) | |
First Name | |
Last Name | |
E-mail | |
Address 1 | |
Address 2 | |
City | |
Province | |
Postal Code/Zip | |
Country | |
Additional Tribute Card | |
Type of Gift: | |
Name of person being honoured or in whose memory the donation is being made: | |
Name of person to whom the Tribute card is destined: | |
Personal message to print in card: | |
First Name | |
Last Name | |
E-mail | |
Address 1 | |
Address 2 | |
City | |
Province | |
Postal Code/Zip | |
Country | |
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