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* $1800.00 $1000.00 $540.00 $360.00 $180.00 $100.00 $54.00 Other

Gift Amount:*

Purpose* Choose a PurposeGeneralMonthly Giving Chai ClubMikvah FundSeder KitsJewish Art CalendarLecture SeriesRosh Hashana DinnerKiddush SponsorshipHoliday ProgramsSteve Gersten Camp Gan Israel Endowment FundCapital Building FundPassover SederChabad Endowment FundJewish Learning InstituteCamp Gan Israel

Billing Information

First Name:*

Middle Initial:

Last Name:*

Address Line 1:*

Address Line 2:

City:*

Province/State* Choose a Province/StateAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Postal/Zip Code*

Phone:*

Credit Card Information

Card Number:*

Secure Code:*

Expiration Month:* MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Expiration Year:* Year20182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040

Credit Card/Banking Information

Method of Payment* Credit Card Automated Account Debit

Card Number:*

Secure Code:*

Expiration Month:* MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Expiration Year:* Year202020212022202320242025202620272028202920302031203220332034203520362037203820392040

Card Brand:* Choose a CardAmerican ExpressDiscoverMaster CardVisa

Transit Number*

Financial Institution Number*

Account Number*

Additional Notes/Comments

Notes

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