PAFPPAC Pledge Information

Please complete the form below to make your PAFPPAC Contribution Pledge. Thank you for your support!

First Name:

Last Name:

Home Address:

City

State

Zip Code

Phone No.:

Email:

Employer Name:

PAFP Affiliation:

Other Affiliation:

Donation Amount:

Payment Options

I am making full payment now:

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Credit Card Information

PLEASE TAKE NOTICE: PAFP will be adding a 3.0% credit card transaction processing fee to help offset the rising costs of doing business through electronic payments. Thank you for your understanding and cooperation. The total amount charged to your credit card will be: $154.50.

Credit Card No.:

Credit Card Expires:
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Name on Card:

Security Code:

Billing Address:

Same as Home Address

City

State

Zip Code

Form Verification:

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