___$500 ___$250 ___$100 ___ $50

___ other one-time gift $________________

___ monthly gift $ ______________________

___1st of the month ___15th of the month

___ my check is enclosed ___ credit/debit

name __________________________________

address ________________________________

city, st & zip ___________________________

email __________________________________

card number ___________________________

expiration date ______ csc code __________