Foundation Donation

Contact Information

AAFP ID#: *

Member Type: *

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip Code: *

Home Phone Number: *

Cell Phone Number: *

Office Phone Number: *

Email Address: *

Donation Amount: (choose one) *

If you marked other, how much would you like to donate?

Is this a recurring donation? (choose one) *

One-time Donation

Monthly Donation

If you marked monthly donation, how long would you like to make this monthly donation?

I would like this donation applied to the following: *

Credit Card Type *

Mastercard

Visa

American Express

Discover

Cardholder's Name *

Credit Card Number *

Expiration Date *

Security Code *

Billing Address: *

City: *

State: *

Zip Code: *