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First Name:
Last Name:

Name must match name on credit card.

Address:
City:
State:
Zip:
Country:
E-Mail:
Day Phone:
( ) -
Frequency:

Monthy donations must be greater than $20.00 to be processed.


Amount:

Amounts are in US dollars . Enter numbers only (i.e. Enter $5,000.00 as 5000) .


Designation:

Enter information to further clarify the designation in the Notes. (i.e. Resident Support requires the resident's name - please enter below).


Notes:
Card Type:
Card Num:
Exp. Date :


For a donation of $25 or more you may select one of the available gifts to be mailed to the billing address given above. (This does not apply to Resident Support donations).


I authorize TLC to charge my account the amount I entered above (this includes my authorization for TLC to reverse any charges made in error). This authority will remain in effect until I give written notice to cancel it. I also understand that my donation is nonrefundable.

I agree with the terms above.

 
 
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