FAIAPAC/IMPACT Pledge Card

Please fill in the information requested below. Fields with an * are required.
*Name:  
*Agency Name:  
*Member ID:  
*Mailing Address:  
*City:  
*State:
*Zip:  
*Work Phone:  
*Cell Phone:  
Fax:
*Email:    


By filling out this form, you are contributing to FAIAPAC.
I pledge the following:
An individual contribution of $100
(check box):
An individual contribution of: $
An agency contribution of: $
TOTAL CONTRIBUTION: $
I would like my contribution to go to:


Credit Card Information
*Credit Card:
*Credit Card Number:               
*CVV Code:  
*Expiration Date (mm/yy):  
*Billing Address:  
*Billing City:  
*Billing State:
*Billing Zip:  
*Name On Card:  
CREDIT CARD CHARGE AUTHORIZATION AGREEMENT
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