International Association of Insurance Professionals

Donations - Secure Online Donation Form

Campaign/Fund Information
Campaign/Fund *	roz horton scholarship or Select a Different Fund

Donation Information
Donation Amount *	$
Payment Method *	Check/Money Order ACH/E-Check (US banks only) Credit Card
In memory of:	If this donation is in memory of someone, please provide the name.
In honor of:	If this donation is in honor of someone, please provide the name.
Donor Comments

Donor Information

First Name *
Middle Name
Last Name *
Suffix
Organization
Email *
Address *
Address Cont.
City/Town *
Country *
State	(Reset)
Postal Code*
Phone *

Billing Information
[ Click here if billing address is the same as donor address ]
Name on Card *
Card Type *
Card Number *
Card CVV Num *	What is this?
Exp. Date *	/
Account Type *
Account Number *	(confirm)
Bank Code *	(Routing Number)
Organization
Address *
Address Cont.
City/Town *
Country *
State	(Reset)
Postal Code*
Billing Phone *

The Cardholder stated above has authorized this payment. If this payment is part of a recurring series of payments, the Cardholder understands the terms and amounts of those recurring payments, and authorizes payment for each of them. Cardholder consent will expire once all scheduled recurring payments have been processed, or if all future recurrences are cancelled. The Cardholder acknowledges that specific payment dates may vary. Examples include, but are not limited to: payment dates falling during weekends, holidays, or during system outages. In order to facilitate the processing of those recurring payments, stored credentials will be used. Those stored credentials will only be used to process payments that are part of this series of recurrences. In order to use those stored credentials for any other payment, Cardholder re-authorization will be required. In the event that a consent agreement must be modified, the new agreement will be sent to the email address associated with the invoice.

The Cardholder understands the terms and authorizes the payment(s).

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