Credit/Debit
Name
First Name
Last Name
Email
Confirmation Email
example@example.com
Selection:
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( X )
Payment to Val Rodgers
Select payment amount from drop down menu
$
5.00
Amount
$5
$10
$15
$20
$25
$30
$35
$40
$45
$50
$55
$60
$65
$70
$75
$80
$85
$90
$95
$100
$105
$110
$115
$120
$125
$130
$135
$140
$145
$150
Submit
Should be Empty: