Online Donation Form

Online Donation Form

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Donation for:

Gift Type:

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Payment Method:

Credit CardBank Account (ACH)

Payment Information

Name on Card

Card Number

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Code

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Payment Information

Name on Account

Bank Name

Bank Routing Number

Bank Account Number

Billing Account Number

Account Type

CheckingSavings

Billing Information

First Name

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Address Line 1

Address Line 2

City

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Email

Yes, I would like to receive communication from Epilepsy Foundation of Minnesota

Yes, this is an honor or memorial gift

Honor/Memorial Information

Honor Gift Type:

Honoree/Memorial Name

Notification Recipient Name

Notification Recipient Street

Notification Recipient City

Notification Recipient State

Notification Recipient Zip Code

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