Automatic Monthly Gift

* Denotes required fields

*Title: 

Select Title Mr. Mrs. Ms. Dr. Professor

*First Name:  

Middle Name or Initial:  

*Last Name: 

*Mailing Address:

*City:

*State /Province:

Select State or Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ------------------------------ American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands ++++++++++++++++++ CANADA ================== ALBERTA BRITISH COLUMBIA MANITOBA NEW BRUNSWICK NEWFOUNDLAND NUNAVAT NOVA SCOTIA ONTARIO PRINCE EDWARD ISLAND QUEBEC SASKATCHEWAN NORTHWEST TERRITORIES YUKON TERRITORY

*Zip/PC:

*Country:

*Phone:

*E-mail:

*Monthly Donation: 

 US$  

* 

I would like this transaction to occur on the 1^st or the 15^th of each month (or on the next business day when these dates fall on a weekend or holiday). 

By submitting this form, I agree to have my debit/credit card charged monthly by the A-T Children’s Project. I can stop or change this arrangement immediately at any time by contacting the
A-TCP office directly.   I agree I disagree

*How did you first hear about us?              Please Make a Selection... Website Friends I am the parent of a person with A-T. I am a relative of a person with A-T. I am the teacher of a person with A-T. I am the physician of a person with A-T. I attended a fundraiser for ATCP. Other           

Notes:

Your first gift will be automatically processed when you sign up on the Verisign® web site.  From the next month on, your debit/credit card will be charged monthly by the A-T Children’s Project. Please note that only debit cards that have the VISA or Master Card logo on the front will be accepted. At this point, electronic funds transfer with checks is not available.

To complete your transaction click on the "submit" button to enter the secure site where you will enter your credit card information  This may take a few moments. Thank you for your patience.

Click only once.
Do not press the "back" or "refresh" buttons.