WELI Donation Form

SPA is a 501(c)3 organization, and contributions are tax deductible.

CONTRIBUTOR

First Name:

Last Name:

Degree:

MD DO PhD
Other (specify)

CONTACT INFORMATION

Billing Address:

City:

State:

Zip:

Email Address:

PAYMENT AMOUNT

In memory of: (optional)

In honor of: (optional)

Suggested Donation Amounts

	$1000.00
	$500.00
	$250.00
	$100.00
	$50.00
	Other: $

PAYMENT TYPE

	Paying by check (Make check payable to SPA. Payment instructions will be in email sent after contribution submission)
	Paying by credit card (Please fill out credit card information below)

CREDIT CARD INFORMATION

The following is ONLY required if choosing to make your payment by credit card.

Credit Card Type:

VISA MasterCard AMEX Discover

Card Number:

Security code:

For VISA or MasterCard it is on the back of your card in the signature box. The 3-digit code is printed on the right-hand side of your 16-digit credit card number.
For American Express the code is the 4-digit number printed on the front of your card either on the right-hand side directly above the credit card number or the left-hand side directly above the credit card number.

Expiration Date:

Credit Card Billing Address:

Credit Card Zip Code:

Card Holder Name: