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 or holiday 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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