Request edit access
June 2017 Summer Solstice Sustaining Donor Drive
If you would like to enjoy the convenience of automatic recurring billing, simply complete the Credit Card Information section below and sign the form. All requested information is required. Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement.

You may cancel this automatic billing authorization at any time by contacting rose@revelsnorth.org or calling 866-556-3083.

Thank you for helping us meet our Mid Year Appeal goal.
All information submitted will remain confidential.

First Name *
Your answer
Last Name *
Your answer
Street *
Your answer
Town *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone *
Your answer
Email Address *
Your answer
Monthly Donation Amount *
Is this gift to be anonymous? *
Is this gift in memory of David Gay? *
Credit Card Type *
All account information will be kept private.
Credit Card Number *
All account information will be kept private.
Your answer
Credit Card Expiration *
Your answer
Credit Card CVV# *
3 numbers on the back of your card
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Revels North. Report Abuse - Terms of Service - Additional Terms