Donation Gift amount: $100 $200 $300 $500 $1,000 Other Amount: Designation Designation: USA Wheelchair Rugby other Designation: Recurring Gift Make this a recurring gift Give monthly quarterly annually on day 1 of each month Your first gift will occur on 8/1/2020 Billing Address Make this gift on behalf of an organization Organization name: Name: Title: title Mr. Ms. Mrs. Dr. Miss Master Prof. The Honorable Judge Rabbi Reverend Sister Father Brother Lt. Capt. Major Cmdr. Col. Admiral General Ambassador Senator Governor Sir Madam Sir/Madam Drs. Sr. Rep. Colonel Coach and Mrs. LTC (Ret.) Councillor Mayor LTCOL and Mrs. Maj. Gen. (Ret) Commissioner CSM Sgt. Hon. Cantor Coach Cdr. Representative LTC Rev. Dr. and Mrs. Mrs SSG President Brigadier Sargeant Govenor First name: Last name: Email: Country: United States Canada United Kingdom Australia New Zealand Address: City: State & zip: State: state AA AB AE AK AL AP AR AS AZ BC CA CO CT CZ DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NL NH NJ NM NS NT NV NY OH OK ON OR PA PE PR PW QC RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT NU ALA Zip: City & county: City: County: county (optional) Henry Calhoun Collier Baltimore Tuscaloosa De Kalb Kenton Limestone Putnam New Hanover Saginaw Oklahoma Westmoreland Middlesex Johnson Hernando Cochise Escambia Lee Coffee Morris Maury Contra Costa Saint Tammany Chilton East Baton Rouge Forsyth Robeson Walker Kerr Duval Anne Arundel Mercer Smith Alameda Los Angeles Campbell Etowah Horry Talladega Wilson Travis Santa Clara Kootenai Pinellas Jefferson Craven Mecklenburg Polk Walton Mclean Washoe Hunt Lancaster Troup Fort Bend Columbia Durham Henderson Lubbock Galveston Tallapoosa Multnomah Bryan Caddo Bergen Rutherford Dale Henrico Ventura Oktibbeha Nassau El Paso Rockwall Chatham Norfolk Hillsborough Essex Butler Ramsey Clarke Arapahoe Boulder Bernalillo New York Pima San Diego Palm Beach Hot Spring Will Jones Hubbard Denver Onondaga Kent Philadelphia Monroe Arlington Fairfax Fairfax City Douglas Cobb Sebastian Franklin Houston Fulton Gloucester Eau Claire New London Monongalia Honolulu Randolph Ascension Blount Summit Jackson San Miguel Dekalb Norfolk City Worcester Martin Ozaukee Loudoun Morgan Clay Shelby Kings Okaloosa District Of Columbia Suffolk Warren Mcpherson Anderson Santa Barbara Collin Mesa Colbert Williamson Barnstable Saint Francis Pickens Dallas Monterey King Sumter Crawford Lake Washington Richmond Reeves Harford Hamilton Greenville Marshall Virginia Beach City Garland Lauderdale Lea Camden Brevard Coosa Cook Winston Windham Bonner Linn Hays Elmore Broward Pitt Brunswick Muscogee Scott Bay Bexar Prince Georges Pinal Rockingham Fairfield Denton Fayette San Mateo Lawrence Livingston Cumberland Saint Clair Macon Milwaukee Saint Louis Hendricks Bullock Eclectic Lincoln Maricopa Knox Kershaw Potter Alexandria City Brazos Montgomery Lafourche Stafford Butts Davidson Seminole Harris Clermont Charleston Bibb Guilford Lane Richland Desoto Monmouth Boone Orleans Walworth Madison Leon Saint Johns Hudson Tarrant Westchester Marion Hennepin Rockdale Zavala Autauga Greene Buncombe Cleburne York Lowndes Luzerne Glynn Hanover Pike Volusia Crenshaw Windsor San Francisco Hancock Allegheny Catawba Howard Mobile Baldwin Coweta Butte Indian River Perry Santa Rosa Russell Chester Chambers New Haven Lafayette Sonoma Oakland Gwinnett Riverside Hood Dauphin Colquitt Cullman Sedgwick Culpeper Wayne Wake Cuyahoga Queens Orange Miami-dade Sarasota Erie Providence Twin Falls Postcode: City: Province & postal: Province: province AA AB AE AK AL AP AR AS AZ BC CA CO CT CZ DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NL NH NJ NM NS NT NV NY OH OK ON OR PA PE PR PW QC RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT NU ALA Postal: Suburb: State & postcode: State: state AA AB AE AK AL AP AR AS AZ BC CA CO CT CZ DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NL NH NJ NM NS NT NV NY OH OK ON OR PA PE PR PW QC RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT NU ALA Postcode: Suburb: suburb City & post code: City: city Post code: I would like this gift to remain anonymous Payment details Payment Processed by Blackbaud Cardholder name: Card number: Card type: <Please Select> Visa American Express Discover JCB Maestro MasterCard Expiration: Month: month 01 02 03 04 05 06 07 08 09 10 11 12 Year: year 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 CSC: Is the information you entered to set up the Direct Debit Instruction correct? Account holder: Sort Code: Account number: Amount to be debited: Collection frequency: Date of first gift:
