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Chabad of Regina Donate Form
Donor E-Mail
Important: Enter a valid e-mail address. Receipts will be sent to this address.
E-Mail:*
Donation Information
Donation Type:*
Single Gift
Monthly Gift
Annual Gift
Gift Amount:*Amount of donation
Purpose*Choose your fund
Billing Information
First Name:*
Middle Initial:
Last Name:*
Address Line 1:*Where your statement is mailed
Address Line 2:Apt. or Suite No.
City:*
Province/State*
Postal/Zip Code*
Phone:*
Credit Card Information
Card Number:*No dashes or spaces please
Secure Code:*3 or 4 digit security code
Expiration Month:*From your card
Expiration Year:*From your card
Credit Card/Banking Information
Method of Payment*
Credit Card Automated Account Debit 
Card Number:*No dashes or spaces please
Secure Code:*3 or 4 digit security code
Expiration Month:*From your card
Expiration Year:*From your card
Card Brand:*
Transit Number*
Financial Institution Number*
Account Number*
Additional Notes/Comments
Notes
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