SECURE PAYMENT FORM
*
Indicates a required field
Reoccurring Donation Summary
Order Date
Invoice Number
Customer IP
Description
Billing Amount
Schedule
Disabled
Daily
Weekly
Biweekly
Monthly
Bimonthly
Quarterly
Biannually
Annually
Total transactions of recurring billing
Credit Card Information
Name as on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date
CVV2/CID
Donor Information
First Name
Last Name
Address
City
State
Zip
Country
Phone Number
Email Address
Employment Info
*
Are you Retired?
Yes
No
Contribution Rules
I am a U.S. citizen or lawfully admitted permanent resident (i.e., green card holder). This contribution is made from my own funds, and funds are not being provided to me by another person or entity for the purpose of making this contribution. I am making this contribution with my own personal credit card and not with a corporate or business credit card or a card issued to another person. I am at least eighteen years old. I am not a federal contractor.
Submit
www.vote4augie.com
Paid for by Friends of Augie. PO Box 2765 - Ewa Beach, HI 96706.
Powered by AXIA PAYMENTS HAWAII