Payment form

St. Anthony (Shirley)

First Name

Last Name

Email Address

Phone Number

Amount

$5

$10

$25

$50

$100

$250

$500

$1000

Other…

$

Credit or debit card

Address

City/Town

State/Province

Earmark:

This should be a:

One time transaction

Recurring transaction

This transaction will recur until you request it be stopped.

Frequency

Weekly

Monthly

Annually

Comments

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