The Panhandle Gives
Early Donation Form
Contact Name
*
First Name
Last Name
Email
*
example@example.com
Organization/ Business (if applicable)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Fax Number (if applicable)
Please enter a valid fax number.
Amount of Donation
*
Please enter the amount of your donation including dollars and cents. Example - $100.00
Name on Credit Card:
*
Credit Card Number:
*
It is not necessary to include dashes or spaces.
Expiration Date
*
CCV
*
Credit Card Billing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I agree for the amount noted above to be charged to my account within the time frame of The Panhandle Gives campaign (November 25th - December 3rd.) The donation will be made to The Panhandle Gives program for the Moore County Health Foundation, which will use my donation for scholarships for area students in healthcare fields determined by the Moore County Health Foundation guidelines.
*
Submit
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