Billing Information

Name
Name as it appears on credit card
Address
 
City
State
ZIP Code
Email Address
Phone
ex: 123-456-7890
Prayer Intentions

Contribution Amount

One-Time Donation Monthly Donation
$10 $25 $50 $75 $100 $1,000 Other
$

Credit Card Information

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Card Number
Expiration /
CVV2

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American Life League
P.O. Box 1350
Stafford, VA 22555
( please reference the email or program you are responding to )