The Vision Project

Name

This address will receive a confirmation email

Phone

Address

I would prefer to make a monthly gift (or skip to the bottom of this form for a one-time gift).

I give Victory permission to charge/debit my card every month. I understand that at anytime, I can stop payment by emailing or calling Victory. Yes

Full Name on Card

Billing Address

Credit Card Type Visa MasterCard American Express Discover

Credit Card Number

Expiration Date (MM/YY)

Card Identification Number (3 digits on the back of the card or 4 on the front for Amex)

Amount to the charged monthly

I authorize Victory to charge the amount listed above to the credit card listed on this form. I agree to pay for this purchase in accordance to the issuing bank cardholder agreement. (Please date and put your signature in the box to confirm you agree with this monthly transaction.

One-Time Donation

Donation Amount (Please enter your one time gift amount.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Please Fix the Following