AFRMA Donation Form

Donate by credit card by filling out this form and mailing to:

AFRMA, Inc.
9976 Stoudertown Rd.
Baltimore, OH 43105

Name: ____________________________________________________________ Amount: $___________ USD
        (as it appears on your card)

Billing Address: ____________________________________________________________

City: _________________________________________ State/Province _________ Zip ________________

Card Number: ___________________________________ Visa [__] M/C [__] Discover [__] Amex [__]

Expiration: _____/______ CVV Security code ____________ (from back of card..
                                                                                .. AmEx on front of card)

Signature: ______________________________________________________

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