MERCHANDISE INFORMATION:
Item #	T-shirt or Tote	Size	Quantity	

				

				

PAYMENT INFORMATION:
Name on Card	Street Address, City, State, Zip	Credit Card #	Security code	

SHIPPING INFORMATION:
Shipping address if different from above:

Merchandise total donation	Shipping and handling	Total	

              $	
                  $	
                          $	

Cardholder will pay card issuer the amount pursuant to cardholder agreement
	
Cardholder signature															date