Donation Form

I am making a gift/donation to: Diakon Community Services

Special Instructions

Is this in memory or honor of someone?

Memory
Honor
None

Person(s) in {{OnBehalfOf}} of

Name

Address

City

State

Zip

Relationship of person being honored to person being notified of your gift

Gift Amount

$25
$50
$100
$250
$500

Or enter a desired contribution amount in the field immediately below.

$

Make this a monthly donation

Your donation will be made today and on the 7th of each following month using the payment method selected. You may cancel or change this amount at any time.

Payment Info

Credit Card
Bank Account

Card Number

Expiration

Card CVV

First Name

Last Name

Bank Name

Routing Number

Usually located between

symbols on your check. Show me

Account Number

Typically comes before the

symbol. The location and number of digits varies from bank to bank. Show me

Account Type

First Name on Account

Email

Your donation receipt will be sent to this address

We have partnered with Authorize.Net., a leading payment gateway since 1996, to accept credit cards and electronic check payments safely and securely.

We adhere to strict industry standards for payment processing, including:

128-bit Secure Sockets Layer (SSL) technology for secure Internet Protocol (IP) transactions.
Industry leading encryption hardware and software methods and security protocols to protect customer information.
Compliance with the Payment Card Industry Data Security Standard (PCI DSS).

For additional information regarding the privacy of your sensitive cardholder data, please read the Authorize.Net Privacy Policy.

Billing

Company

Address

City

State

Zip

Contact Phone