Giving form
Full Name
*
First Name
Last Name
Phone Number
*
E-mail
*
example@example.com
YOUR DONATION MATTERS!!
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( X )
$5 DONATION = 40 BOTTLES OF WATER
$
5.00
Quantity
1
2
3
4
5
6
7
8
9
10
$10 DONATION = 93 BOTTLES OF WATER
$
10.00
Quantity
1
2
3
4
5
6
7
8
9
10
$25 DONATION = 232 BOTTLES OF WATER
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
$50 DONATION = 456 BOTTLES OF WATER
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
$100 DONATION = 911 BOTTLES OF WATER
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card
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