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Mercy Center Donation Form Copy
Amount
*
$
50
$
100
$
250
$
500
$
1,000
$
Donation Schedule
One Time
Monthly
Quarterly
Annually
Name
First Name
Last Name
Email
Address
Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
In honor/memory of
Name
Add 3% to my total amount to help cover the payment processing fees