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Lotus Circle International Donation Form
Amount
*
$100
$50
$25
$
Donation Schedule
One Time
Monthly
Quarterly
Yearly
Contact Information
Name
First Name
Last Name
Email
Verify Email
Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Organization
Phone
Date
(mm/dd/yyyy)
Custom text
Somatic Experiencing Practitioner or trainee
*
Yes
No
Add 3% to my total amount to help cover the payment processing fees