Contributor Details:
Note: If you are making this payment for someone else, please enter that person's name. Then enter the information for the person paying for the purchase after you submit for payment.
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
District
*
Please Select
Select your district
Carolinas
Florida
Georgia
MD, DC, and DE
New England
North Central
Philadelphia
South Central
Virginia
Western States
Comments:
My Donation
*
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$100 Donation for New Pump
$100.00
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$0.00
$
0.00
$50 Donation for New Pump
$50.00
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$0.00
$
0.00
$20 Donation for New Pump
$20.00
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$0.00
$
0.00
$10 Donation for New Pump
$10.00
$
10.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$0.00
$
0.00
$5 Donation for New Pump
$5.00
$
5.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$0.00
$
0.00
$1 Donation for New Pump
$1.00
$
1.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$0.00
$
0.00
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