| Contact Information | |
|---|---|
| Name | Emad Rouzek |
| Contact Email | Email hidden; Javascript is required. |
| Donation Amount | $1,000.00 |
| Would you like to make it a monthly payment? | Pay this amount one time |
| Total Due | $1,000.00 |
| Raffle Ticket Number | Thanks but I don't want a gift |
| Credit Card Information | |
| Credit Card | VISA XXXXXXXXXXXX5868 Emad Rouzek |
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