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* Mandatory fields

Contact Data

*First name(s)
Individual's first name.
*Last name
Individual's last name.
Indiviodual's email address
*Phone primary
Individual's primary phone number, preferred format(123) 456-7890.
Phone secondary
Individual's secondary phone number, preferred format(123) 456-7890.
*Phone unlisted
Indicates whether phone numbers are unlisted number or not.
*Mailing address1
Individual's US Post Office mailing address
Mailing address2
Individual's mailing address information, i.e. post office box, apartment/unit number, etc.
Individual's city of residence.
*Zip code+4
Individual's zip code, includes 4 digit suffix; i.e. 12345-6789.
Individual's county of residence.
*Donation date
Date donation made.
*Amount ($USD)
Enter only the numeric value of the total dollar amount of donation. Do not include the "$" sign; i.e. 25, 50, 100.
*Donation fund
For multiple donations; enter the total amount of donation and in the comment box specify the specific fund and amount you which to donate too. Example: Total amount $40, Cultural Center $20 & Homeland $20.
Used by donator to make a comment regarding his/her donation.
*May we recognize your donation in the New Rusyn Times? (Annual appeal donations only)
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