Donation Form

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First Name *

Last Name *

Submit as a company

Company Name

Email *

Contact Phone Number *

Address Line 1 *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Donor Opt Out *

No, I do not opt out. I consent to having my name listed.

Yes, I opt out of having my name listed publicly.

FIPPOA and The Pines Foundation may take the opportunity to thank our donors publicly. To continue, click "N". To Opt Out and NOT have your name listed publicly, please click “Y”.

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Card

Cardholder First Name *

Cardholder Last Name *

Cardholder Email

Card Number *

Expiration (MM/YY) *

CVV *

Billing address is the same as mailing address

Address Line 1

Address Line 2

City

State/Province

Zip *

Country

Amount:

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