*Required fields

*Name:

*Address:

*City: *State: *Zip Code:

Email (optional):

*Level of Membership: Individual ($40) Family ($100) Contributing ($250) Supporting ($500) Sustaining ($1,000) Partner ($10,000) Founder ($25,000) Benefactor ($50,000)

Please enter your credit card information below as it appears on your credit card.

*Credit Card Type: Visa MC Discover American Express

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*Expiration Date: January February March April May June July August September October November December 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

*Card Holder Name:

*Card Holder Address:

*City: *State: *Zip Code:

*Signature (required): ____________________________________________

Please fill out this portion, if applicable:

This Membership is: A Gift for In Honor of In Memory of Name:

Please send acknowledgement to:

Name:

Address:

City: State: Zip Code:

Thank You

AVDA is a 501(c)(3) nonprofit charitable organization. Under the Internal Revenue Code, your donation is tax deductible. A copy of the official registration #SC-01783 and financial information may be obtained from the Florida Division of Consumer Services. Registration does not imply endorsement, approval, or recommendation by the State. This organization retains 100% of all financial contributions received.

Fax your membership form to:

Attn: AVDA

Fax Number (561) 265-2102

OR

Mail your membership form to:

Aid to Victims of Domestic Abuse, Inc.

P.O. Box 6161

Delray Beach, FL 33482-6161

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