VDare Foundation Credit Card Fax Donation Form

Please fill out this form and fax it to (860) 361-6365

Name:   _________________________________________________________________

Address:_________________________________________________________________

            _________________________________________________________________

City:      _________________________________________________________________

State:   __________________________________________________________________

Zip:      __________________________________________________________________

Email:   __________________________________________________________________

Phone:  __________________________________________________________________

Name on Credit Card:  ____________________________________________________

Signature:     _____________________________________________________________

VISA  _______  Mastercard _______

Credit Card Number: _______________________________________________________

Expiration Date: __________________________   CID Number: __________________

Amount:  ______ $50

              ______ $100

              ______ $500

              ______ $1,000

              ______ Other: __________