Approved

Name:

Amount:

Card Type:

Card Number:

Authcode:

AVS Result:

CVV Result:

OK

Urgent Covid-19 Oxygen Campaign

Donation Details

Choose Option

$3,000 - I can purchase an entire 10L machine.

$1,000 - I can purchase an entire 5L machine.

$500 - I want to chip in and pay for half of one machine.

$250 - I want to chip in and pay for a quarter of a machine.

$180 - Ten Times Chai

$100 - Supporter

$54 - Three Times Chai

$36 - I want to be part of this endeavor.

Donation Reason In Memory Of In Honor Of

Name

Please Have The Sick Children Pray For me (name for prayer / request)

Add personal message with your gift

Repeated Payments

Ongoing 2 Months 3 Months 4 Months 5 Months 6 Months 8 Months 10 Months 12 Months 18 Months 24 Months 36 Months

Credit Card Details

Pay with Check

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MMYY ^*

CVV

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Personal Information

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Zip code ^*

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Process Payment

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Merch Pay, Inc. is a registered ISO of Wells Fargo Bank, N.A., Concord, CA.

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Credit & Debit Processing | Electronic Check Services | Gift & Loyalty Programs | Customized POS Solutions

Urgent Covid-19 Oxygen Campaign

1467 59th Street
Brooklyn, NY 11219

Tell: 718-256-0045

[response]

ID #[transid]

[created]

[cardholder]

$ [amount]

[cardtype]   [ccnum4]

Authorization Number

[authcode]

AVS Response

[avsresult]

CVV response

[cvcresult]

[otherTransaction]

Thank you for your payment.