Tribute Donation - In Memory of a Person | Midland Humane Coalition (Powered by Donorbox)

First Name

Last Name

Phone

Choose your country

Address

Address 2

Postal Code

City

State / Province

Are you currently employed?

Yes

How would you like the recipient to be contacted?

Postal Mail

Please fix the errors above.

CARD PAYPAL BANK TRANSFER

Card Number

MM / YY

CVC Code

The 3-4 digits on the back of your credit card

Billing ZIP Code

Enter the Zip/Postal code for your credit card billing address

By clicking Donate, you authorise MIDLANDHUMANECOALITION to debit the bank account that you connect to for any amount owed for charges arising from your use of MIDLANDHUMANECOALITION’ services and/or purchase of products from MIDLANDHUMANECOALITION, pursuant to MIDLANDHUMANECOALITION’ website and terms, until this authorisation is revoked. You may amend or cancel this authorisation at any time by providing notice to MIDLANDHUMANECOALITION with 30 (thirty) days notice.

If you use MIDLANDHUMANECOALITION’ services or purchase additional products periodically pursuant to MIDLANDHUMANECOALITION’ terms, you authorise MIDLANDHUMANECOALITION to debit your bank account periodically. Payments that fall outside the regular debits authorised above will only be debited after your authorisation is obtained.

Bank Name

Account Type

Account Last 4

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