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

AFRMA/NADRM
%OHPCC
2280 SR 540
Bellefontaine, OH 43311

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: ______________________________________________________