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Thank You for sponsoring Member Portable Radio!

You selected: Member Portable Radio

Donation Amount :

$ : *

(You may edit the amount above)

1. Personal Information

First Name: *

Last Name: *

Company Name:

Address: *

City: *

State: *

Zip Code: *

Country: *

Phone Number: *

Cell Phone:

Email Address: *

2. Payment Details

Card Type: *

Card Number: *

Exp. Month: *

Exp. Year: *

Security Code: *

This is the 3 or 4 digit number printed on the back signature panel.
It is on the front of the card for American Express.

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3. Additional Information (optional)

Shul Pledge

Please Specify Other Shul

Donation Type

General Donation In Memory Of In Honor Of For The Recovery Of

Name

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Additional Comments:

Please mail a receipt to the address above (in addition to the receipt I will receive via email).

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Flatbush Hatzoloh is a non-profit 501c3 organization.