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Select Gift Amount:*

$150.00 - Freedom Level
$500.00 - Honor Level
$1000.00 - Liberty Level
$2,500.00 - Independence Level
$5,000.00 - Stars & Stripes Level
Other

If Other (or you wish to give additional monies), please enter the amount here.

Billing Information

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Credit Card Type*

Business/Corporate
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Title

Name*

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Suffix

Address*

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Phone Number:*

Email*

Yes, I would like to receive periodic updates and communications.

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If this gift is from someone in addition to yourself, please enter their name below:

Joint Donor Title

Joint Donor Name

First Last

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Honor / Memorial Gift Information

Yes, this is an honor or memorial gift

Honor Type

Choose the memorial gift only if the person you are honoring is deceased.

Honoree Title

Honoree Name*

Notification Recipient Title

Notification Recipient Name*

Notification Recipient Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Message Body*

Message Closing*

Message Signature*

Include the gift amount in the message?*

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Military Service

Have you served in the military?*

Yes
No

Which branches?

Army
Marine Corps
Navy
Air Force
Coast Guard

Years served?

One time donation amount:

$0.00

Thank you so much for your donation to Veterans Count.

Email

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Billing Information

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Honor / Memorial Gift Information

Military Service

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