Your browser does not have JavaScript enabled.
Please turn scripting on in your browser settings.
Please complete this form to make your donation to
Center For The Blind And Visually Impaired
Fields marked with an asterisk (
*
) are required.
YOUR GIFT
*
Donation Amount
$500
$250
$100
$50
$25
$10
Other
Donation Recurrence
How often are you giving this donation?
Once
Daily
Weekly
Biweekly
Semi-Monthly
Monthly
Bimonthly
Quarterly
Semi-Annually
Annually
Gift Designation
Select -other- to specify a fund that is not listed.
Casework program
Computer Assistive Technology (CAT) program
General Fund
IDEAL program
Prevention of Blindness program
-other-
Matching Gift Company
Company that will match your gift.
YOUR INFORMATION
Title
'
+
0
Brig
Capt
Capt.
Congressman
Dr & Mrs.
Dr.
Dr. & Dr.
Dr. & Mrs.
Eld.
Hon.
Honorable
Juanita.
Lady
Lt Col
Lt.c
Ltc
Miss
Mr
Mr A.
Mr M
Mr M.
Mr&mrs.
Mr.
Mr. & Mrs.
Mr.&mrs.
Mr..
Mr/mrs.
Mrs.
Mrs. & Mr.
Ms.
Rev.
Rev. & Mrs
Sen.
Sister
Sr
*
First Name
*
Last Name
Name Suffix
*
Address Line 1
Address Line 2
*
City
*
Country
Select -other- if not listed.
-other-
*
State / Province
Select -other- to specify if not listed.
-other-
*
Postal Code
*
Email
*
Phone
Phone Extension
IS THIS DONATION IN HONOR OR MEMORY OF SOMEONE?
YES
|
NO
Title
'
+
0
Brig
Capt
Capt.
Congressman
Dr & Mrs.
Dr.
Dr. & Dr.
Dr. & Mrs.
Eld.
Hon.
Honorable
Juanita.
Lady
Lt Col
Lt.c
Ltc
Miss
Mr
Mr A.
Mr M
Mr M.
Mr&mrs.
Mr.
Mr. & Mrs.
Mr.&mrs.
Mr..
Mr/mrs.
Mrs.
Mrs. & Mr.
Ms.
Rev.
Rev. & Mrs
Sen.
Sister
Sr
First Name
Last Name
Name Suffix
CONTINUE TO PAYMENT >