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| Secure Donation Form |
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| 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: |
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| Donation Information |
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| You Choose Amount! |
The time is now for change! - $10.00
Educate the public - $25.00 You're doing the right thing! - $50.00 I can make a difference! - $100.00 Repeal the Income Tax - $250.00 Repeal the MBT - $500.00 Other: |
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| Recurring: |
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This transaction is being processed by MICHIGAN FAIRTAX ASSOCIATION using Secure Socket Layer (SSL) Encryption. |
