Donation
Amount
$20
$40
$80
$100
Type of Donation
One Time Donation
Recurring Donation
Where do you want to give
Where most needed
Medical Services
Women & Children
Education
Frequency
Monthly
Quarterly
Annual
Contact Information
First Name
Last Name
Address
City
State/Province
Zip/Postal Code
Home Phone
Work Phone
Email
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Help Us Cover Costs
Simply leave "Yes!" checked below to ensure that 100% of your intended donation is available for our mission.
Yes! I want $0.00 to go to Central American Medical Outreach and I will donate $0.00.
No. I will donate $0.00 and Central American Medical Outreach will cover the processing costs.
Credit Card Information
Card Holder Name
Visa
MasterCard
Discover
AmEx
Card Account Number
Expiration Date
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
25
26
27
28
29
30
31
32
33
34
35
Security Code
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Billing Address
Same As Above
Address
City
State/Province
Zip/Postal Code
Email
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Contact Us
: Central American Medical Outreach | 322 Westwood Ave. Orrville, Ohio 44667 | 330.683.5956 |
[email protected]
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