ACTEC Foundation | Memorial Gift Form

How to Contribute

> Online Contribution Form

ACTEC Foundation
901 15th Street, NW
Suite 525
Washington, DC 20005
T: (202) 684-8460
F: (202) 684-8459

The Lloyd Leva Plaine Memorial Fund

Thank you for your generosity. The ACTEC Foundation is strengthened by your support, and your investment makes a difference — each and every day. You will receive a printed receipt, mailed to your address, within two weeks.

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Amount: * $

Special Comments:

(please limit comments to 200 characters, including spaces)

Contact Information

Mr./Mrs./Dr./etc.:
First Name: *
Middle Name:
Last Name: *
Jr./Sr./etc.:

Spouse/Partner Name (if a joint gift):
First Name:	Middle Name:	Last Name:

Address Line 1: *

Address Line 2:

City: *
State:		ZIP:
Country: *

Phone Number: *

E-mail Address:
An e-mail confirmation will be sent to this address when your gift has been processed.

Payment

Card Type:	Card Number: *	Expiration Date: *
		/
	(no dashes/spaces)	(MM/YYYY)
Name as it appears on card: *

If you are having trouble with this form, please contact us at (202) 684-8460 ext. 8112 between the hours of 9:00 a.m. and 5:00 p.m. Eastern Time, Monday-Friday, or by e-mailing us at webmaster@actecfoundation.org. We will respond to any e-mail inquiries by the end of the next business day.


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