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.Format: (000) 000-0000.
I would like to round up my bill to the nearest dollar for the purpose of donating to my selected charity as indicated below.
Cordova Volunteer Fire DepartmentFriends of the LibraryMiss Iceworm Scholarship FundIndependence FundCordova Family Resource Center
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: