Contribution Payment Form

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Applications must be received no later than September 13, 2018. Authorization notification will be sent on or after October 1, 2018 and no later than October 15, 2018. Payments are not accepted without an authorization number. If you have not yet requested an authorization number, please click here.
Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Email
Donation Amount*
Certificate Authorization Number*
Provided by the Health Research, Inc. office.
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Signature*
Please enter your first and last name
Acceptance*
- I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to let Health Research Inc. charge my credit card for the amount specified as a donation to their organization.
CAPTCHA
Health Research, Inc. is a nonprofit corporation organized under the New York State Nonprofit Corporation Law. It is tax exempt under Section 501 (c) (3) of the Internal Revenue Service Code. Health Research, Inc. Donors are advised to consult their own legal counsel and financial advisors for matters relating to their donations.
Phone
This field is for validation purposes and should be left unchanged.