This page may not work correctly in your current browser, Internet Explorer. We recommend changing to a more modern browser before viewing this page. We recommend Chrome, Firefox, Safari, or Edge. CIVIC DONATION FORM Donation Amount: This is a one time donation Make this a recurring donation Monthly End Date: First Name: Last Name: Company: Email: Phone: Address: Address Line 2 City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix ADDITIONAL DONATION DETAILS Is this an anonymous donation? No Yes Is this being made in honor or in memory of someone? Honor Memory If so, please list the name of the person this gift being made in honor or memory of below: Will your company match this gift? Please list the company name below: Please share matching gift company contact information: Thank you for your support of the CIVIC Leadership Institute! Billing Information Payment method: Credit Card Pay Later E-Check payments can only be processed from United States banks. Credit Card Number: Card Expiration: 01 02 03 04 05 06 07 08 09 10 11 12 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 Credit Card CVV2: Cardholder First Name: Cardholder Last Name: Billing Address: Billing Address Line 2 City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Captcha NOTE: Please only click the 'SUBMIT' button once. Your payment may take time to process. Would you like to pay by check? Please send your check to: CIVIC Leadership Institute 4211 Monarch Way, Suite 116 Norfolk, VA 23508 I will mail a check to the CIVIC Leadership Institute NOTE: Please only click the 'SUBMIT' button once. Your payment may take time to process. Neon CRM by Neon One
