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Please select the type of donation and the amount you would like to donate.*

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if other:*

Recurring Amount:*

if other:*

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Credit Card Information

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Card Number Expiration Date Security Code Name as it appears on card:

Donor's Billing / Mailing Address

Please enter your billing / mailing name and address below. Your billing information must EXACTLY match the address printed on your billing statements.

Name*

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Address*

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Email Address*

Company: (if applicable)

Mailing Information Matches Billing Information?*

Yes
No

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I would like to receive a presentation certificate for my gift of $150 or more*

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No

Presentation Certificate Information

The Wheelchair Foundation Wishes To Thank:*

For The Gift Made In The:*

*

Presentation Folder Mailing Address Same As Billing Address?

Yes
No

Presentation Folder Mailing Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How did you hear about Nevada Wheelchair Foundation?

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Other

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Credit Card Information

Donor's Billing / Mailing Address

Presentation Certificate Information

How did you hear about Nevada Wheelchair Foundation?

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