BIIS Gift of Empowerment

First Name: Last Name: Email: Address: City: State/Province: Zip Code: - Suggested Donation Amounts:

$30

$60

$75

$100

$250

$500

$50

Other (Write-in Amount)

$30

$60

$75

$100

$250

$500

Other (Write-in Amount)

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Billing Information

Payment method: Credit Card
American Express

American Express

Discover

MasterCard

Visa

E-Check

Donor's Billing Information

Billing Address

Card:

Cardholder First Name: Cardholder Last Name: Zip Code: -

Card Information

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E-Check Billing Information Routing Number: Account Number: Account Type: Account Holder First Name: Account Holder Last Name: Billing Country:

NOTE: Please only click the 'SUBMIT' button once. Your payment may take time to process.

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