Texas Pharmacy Association

Donations - Secure Online Donation Form

Campaign/Fund Information
Campaign/Fund *	TPF MCMLXX Society or Select a Different Fund

Donation Information

Donation Amount *

$19.70
OTHER: $

NOTE:

The minimum donation amount is $19.70

Payment Method *

ACH/E-Check (US banks only)

Credit Card

Donation Type *

One-Time Donation
Recurring Monthly Donation (until cancelled)
Split this Donation into Monthly Payments

Number of Payments *

Validation *

What is 2 + 5? Type your answer in the box above.

Donor Comments

Donor Information

First Name *
Middle Name
Last Name *
Suffix
Organization
Email *
Address *
Address Cont.
City/Town *
Country *
State	(Reset)
Postal Code*
Phone *
Valid for Radius Search Only

Billing Information
[ Click here if billing address is the same as donor address ]
Name on Card *
Card Type *
Card Number *
Card CVV Num *	What is this?
Exp. Date *	/
Account Type *
Account Number *	(confirm)
Bank Code *	(Routing Number)
Organization
Address *
Address Cont.
City/Town *
Country *
State	(Reset)
Postal Code*
Billing Phone *

The Cardholder stated above has authorized this payment. If this payment is part of a recurring series of payments, the Cardholder understands the terms and amounts of those recurring payments, and authorizes payment for each of them. Cardholder consent will expire once all scheduled recurring payments have been processed, or if all future recurrences are cancelled. The Cardholder acknowledges that specific payment dates may vary. Examples include, but are not limited to: payment dates falling during weekends, holidays, or during system outages. In order to facilitate the processing of those recurring payments, stored credentials will be used. Those stored credentials will only be used to process payments that are part of this series of recurrences. In order to use those stored credentials for any other payment, Cardholder re-authorization will be required. In the event that a consent agreement must be modified, the new agreement will be sent to the email address associated with the invoice.

The Cardholder understands the terms and authorizes the payment(s).

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