Individual

First Name

Last Name

Country

Address

City

State

Postal code

Email	Phone
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Employer

Occupation

Employer Country

Employer City

State

Postal code

Law requires we ask for your employer and occupation. If you don't have an employer or are retired, put N/A, and if you are self-employed put "self-employed" in employer and describe your occupation.

Contributions are not tax deductible.

Amount

$20.00

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