American Legion Auxiliary

Secure Payment Form

Donation Summary

Order Date

Donation Amount

Surcharge Fee (2.91%)

Total Amount

Fund Donating To

Description

Include any additional information such as name of who the donation is in memory of or special instructions.

Who to Send Acknowledgement To

In Memory of

First Name

Last Name

Address

Address 2

City

State

Zip

Country

Phone Number

Credit Card Information

Name as on Card

Card Billing Address

Card Billing Zip

Card Number

Card Expiration Date

CVV2/CID

Billing Information

Unit Name

First Name

Last Name

Address

Address 2

City

State

Zip

Country

Phone Number

Email Address