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FACTPAC Donation
Customer E-Mail
Important: Enter a valid e-mail address. Receipts will be sent to this address.
E-Mail:*
Billing Information
First Name:*
Same name as on your card
Middle Initial:
Last Name:*
Company
Address Line 1:*
Where your statement is mailed
Address Line 2:
Apt. or Suite No.
City:*
State:*
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:*
Phone:*
Organization Represented
Select
Organization Represe
AI Austin
AI Central Texas
AI Heart of Texas
AI Houston
AI North Texas
AI Rio Grande
AI South Texas
AI Texas Plains
ASA Corpus Christi
ASA Dallas-Fort Worth
ASA El Paso
ASA Houston
ASA San Antonio
ASFMRA - Texas
NAIFA Austin
NAIFA El Paso
NAIFA Fort Worth
NAIFA Greater Dallas
NAIFA Houston
NAIFA Panhandle Plains
NAIFA Waco
Other
Donation Information
Donation Level*
Diamond Club $500
Gold Club $250
Silver Club $100
Supporter Club $50
Other $
Donotion Type*
Choose a Donotion Type
Individual - Can be used towards legislative donations
Corporate - Can only be used for administrative funds
Prefer individual donations
Anonymous Donation
Do not list name as donor
Gift Amount*
Amount of donation
Payment by PayPal will be available on next screen. If you do not wish to use credit card you can print page and mail donation to:
FACT
1321 Antoine Drive
Houston, TX 77055
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