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First Name

Last Name

Home Address

City

State

Zip Code

Email Address

Phone Number

Donation Details

Is this donation for the Stillwater Strong Relief Efforts?

Yes

Type of Gift:

Individual

Business/Corporate

Other…

Company or Business

Employer or Organization

Department

Employee ID#

Make my gift anonymous.

Yes

Donor Notes & Financial Authorization

Donor Notes

I authorize the financial transactions and terms above.

Yes, I agree and authorize.