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Donation

* Mandatory fields
Suffix
*First name
Middle Int
*Last name
Please include your degree
*Birth Date
*Degree
*Email
*Gender
*Practice Name
Specialty Certified?
Home Address 1
*Amount ($USD)
Acknowledgement
Acknowledgement - Comment
Your Name
Your Phone

IMPORTANT - Contributions to 501(c)(6) organizations are not tax deductible as charitable contributions.

 

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