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Vote 4 Values Registration - Elkhart 10/20/08

DONATE ONLINE!

EMAIL ADDRESS:

FIRST NAME:

LAST NAME:

COUNTY:

STREET ADDRESS:

CITY:

STATE/PROVINCE:

ZIP/POSTAL CODE

PHONE: Home Work Cell

AMOUNT: ($10 per person)

CREDIT CARD: --- 3 digit code

EXP DATE: /

NAME AS APPEARS ON CARD:

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DONATE ONLINE!
EMAIL ADDRESS:
FIRST NAME:
LAST NAME:
COUNTY:
STREET ADDRESS:
CITY:
STATE/PROVINCE:
ZIP/POSTAL CODE
PHONE:	Home Work Cell
AMOUNT:	($10 per person)
CREDIT CARD:	--- 3 digit code

EXP DATE:	/
NAME AS APPEARS ON CARD: