FACTPAC Donation

Customer E-Mail
Important: Enter a valid e-mail address. Receipts will be sent to this address.
E-Mail:*
Billing Information
First Name:*		Same name as on your card
Middle Initial:
Last Name:*
Company
Address Line 1:*		Where your statement is mailed
Address Line 2:		Apt. or Suite No.
City:*
State:*
Zip Code:*
Phone:*
Organization Represented
Donation Information
Donation Level*	Diamond Club $500 Gold Club $250 Silver Club $100 Supporter Club $50 Other $
Donotion Type*		Prefer individual donations
Anonymous Donation	Do not list name as donor
Gift Amount*		Amount of donation
Payment by PayPal will be available on next screen. If you do not wish to use credit card you can print page and mail donation to: FACT PO Box 202197 Austin, TX 78720
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