Center for Community Innovation Online Donation Form


Secure Online Donation Form

Please note that fields with an asterisk (*) are required.

*Donation amount $:  .00                  
*Donation Frequency: 

If you chose a monthly frequency, please indicate the date you would like us to charge your account.

*First Name:  *Last Name: 
*Address 1:  Address 2: 
*City:  *State: 
*ZIP Code:  *Email: 
*Preferred Phone #:  Alternate Phone #: 



*Payment type:    Credit Card   E-Check (helps eve more) 

If by Credit Card: 

If by E-Check: 
*Credit Card Type: 
*Credit Card #:  *Routing #:  Where do I find this?
*Exp. Date:  / *Checking Account #::  Where do I find this?


If this gift is being made   in honor   in memory   N/A 
Please provide Full Name of person being honored/remembered:
Name, Address, Email address of person that should be notified of your tribute gift:
(No commas, please.)

My employer is a matching gift company  Yes   No   N/A 
My spouse's employer is a matching gift company  Yes   No   N/A 
Employer information: (No commas or characters, please.)


After ensuring that all of the information above is correct,
please click the Submit Form Now button ONLY ONCE.
Multiple clicks of the Submit button will result in duplicate charges to your account.
An email confirmation will be sent to the email address you provided.


 

  
Center for Community Innovation
1255 Broadway NE, Suite 110, Salem, OR 97301 - Phone: 503.581.9922 - Fax: 503.581.9925 - Email:info@ccioregon.org


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