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Hurricane Michael Relief Donation Form

AIA Florida is collecting contributions to purchase much needed supplies to bring to areas affected by Hurricane Michael.

Highlighted fields are required. (Note: You may also mail your donation.)

First Name:
Last Name:
Company Name:
Address:
City:
State:
Zip Code:
Phone:
E-Mail:

Donation Amount

Amount:

Credit Card Information

Credit Card Type
Name on Credit Card
Credit Card Number
Credit Card Expiration /
Card Security Code
On Visa & Mastercard, the 3 digit code on back of the card. For American Express, the 4 digit code on the front of the card printed above and to the right of the raised credit card number.
Comment:

In order to prevent automated systems from submitting this form, Please answer this math question to validate your message:

What is 10 + 3?

Mail Your Donation

You may also mail your donation to:

AIA Florida
104 E. Jefferson St.
Tallahassee, FL 32301

 

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