Chabad of Regina Donate Form

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:*Amount of donation
Billing Information
First Name:*Same name as on your card
Middle Initial:
Last Name:*
Address Line 1:*Where your statement is mailed
Address Line 2:Apt. or Suite No.
City:*
Province/State*
Postal/Zip Code*
Phone:*
Credit/Debit Card Information
Card Number:*No dashes or spaces please
Secure Code:*3 or 4 digit security code
Expiration Month:*From your card
Expiration Year:*From your card
Card Brand:*
Additional Notes/Comments
Notes
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