Friends of Karen - Acceptiva

Donor Information

Salutation:

First Name: *

Middle Name:

If not applicable enter 'none'.

Last Name: *

How You Prefer To Be Addressed:

For example, if your name is Elizabeth, do you like to be called Betsy or Liz or something else?

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone:

E-mail: *

a receipt for your donation will be e-mail to this address.

Company

Company / Organization Name:

This donation is on behalf of a Company or Organization.

My employer will match my gift.

Making a gift in honor or in memory of a special person is a wonderful way to recognize them and provide hope and comfort to others. If you would like, we will send a letter to a recipient of your choice informing them of your thoughtful gesture.

Tribute Type:

Full Name of Honoree:

If you wish us to send a notification letter, please provide the following recipient information.

Salutation:

Name:

Address:

Address 2:

City:

State:

Zip Code:

Special Message:

Your Payment Information

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *