Foundation Donation

Contribution Type

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Name

First Last

Year of Birth

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Year of Death

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Name to Ship Plaque to

First Last

Club Name*

Highest Office Achieved & Year

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

CC Transaction Fee

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Kids Need Kiwanis