Givers Information

*First Name

Middle Name

*Last Name

*Member ID

*Rank

*Email Address

*Address

*City

*State

*Zip Code

*Phone Number

Campaign Code

24AFSAGFT

Gift Recipients Information

*First Name

Middle Name

*Last Name

*Rank

*Component

*Status

*Date of Birth

*Email Address

*Phone Number

*Address

*City

*State

*Zip Code

Member Chapter Assignment

*Membership Type

*Membership Term

Life Membership Term

Gift Recipients Information

First Name

Middle Name

Last Name

Rank

Component

Status

Date of Birth

Email Address

Phone Number

Address

City

State

Zip Code

Member Chapter Assignment

Membership Type

Membership Term

Life Membership Term

Billing Information

*Credit Card Number

AMEX enter '0' before card number

*Name on Card

*Expiration Date

*Security Code

Visa/MC/Disc enter '0xxx' AMEX enter 'xxxx'

*Auto Renew

Billing address same as personal address

*Billing Address

*Billing City

*Billing State

*Billing Zip Code

Electronic Signature

Type your name to electronically sign the form.

*Signature