Holiday Hero On-Line Donation
 
Please complete the form below to make your Holiday Hero donation.
If you encounter problems using the online donation screen, please send an email to cmoll@cetechnology.com
 
Fields with an asterisk (*) are required.
Donor Information
Individual or Company:   
Salutation (Mr.,Mrs,Etc.):*  
                   
Name(First/MI/Last):*   / /      
Address Line1:*    
Address Line 2/3 (if any):   /
City/State: *   /
Zip: *    
Phone:   (H)  (W)
Payment Information
Name as it Appears on Card:*  
Donation (US Dollars):* $  
Credit Card Type:*
Credit Card Number:*  
Expiration Date:*
Credit Card Security Code:* What is this?
Holiday Hero Information
Categories
What is a Holiday Hero? Diamond.... ...$500.00 or more.
Gold................$100.00 to $499.99.
Silver.............$50.00 to $99.99.
Bronze..........$25.00 to $49.99.
Select one of the following:*
Publish my name, or organization in the announcement as follows (40 char limit):  
OR In memory of (40 char limit):(eg. Our daughter Kris / Bob and Theresa Mullins):  
Do not publish my name/organization:  
Indicate how You Want Your Listing to be Sorted (Ex. If listing is "Carl Patrick Moll" you would want to list it under "Moll Carl Patrick"):  

Only contributions of $25.00 or more will be listed in Business First unless indicated by anonymous notation above. AROCC will have sole discretion as to placement and layout. All donations will be acknowledged and are greatly appreciated.
Deadline for ad placement to assure publication must be received by Friday, December 14th , 2007.

Email: *  
Re-enter Email: *