Bill Round-Up Opt-In

Bill Round-Up Opt-In
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
I would like to round up my bill to the nearest dollar for the purpose of donating to my selected charity as indicated below.
Chose one:

Cordova Volunteer Fire DepartmentFriends of the LibraryMiss Iceworm Scholarship FundIndependence FundCordova Family Resource Center
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: