A D R O P Secure Online Donation Form

Secure Online Donation Form
Please note that the fields with an asterisk (*) are required.

*First Name:  *Last Name: 
*Address 1:  Address 2: 
*City:  *State: 
*Zip Code:  *E-mail: 
*Daytime Phone:  Evening Phone: 


*Amount:    $  .00 (No commas, spaces or characters, please)

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

My donation is in Honor of:
My donation is in Memory of:

Matching Gift Program
If you have a workplace non-profit contributing gift matching program, please provide information about the program such as percentage matches, the contact person at your company or any other useful information enabling A D R O P to further benefit from your participation in our program.

Would you like to add your name to A D R O P’s mailing list?  Yes   No   Already on mailing list 

About SSL Certificates

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 credit card.
An email confirmation will be sent to the email address you provided.

259 North Lawrence Street
Philadelphia, PA 19106
Phone: 215-925-3566 / Fax: 215-627-2003
E-mail: jedeegan@comcast.net

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