Greater Boston/ Mattapan Technology Learning Center
Haiti Earthquake Victims Relief

Complete this form to make a donation to help the victims of Haiti's earthquake that hit on Tuesday, January 12, 2010.  All money collected will go directly to assist victims through a group of existing organizations functioning in Haiti.

Please provide the following contact information:

First Name
Last Name
Organization
Street Address
Apt.
City
State
Zip Code
Country
Work Phone
Home Phone
E-mail

Please provide the following billing information:

BILLING INFORMATION
16 Digit Credit Card Number #:
Expiration Date: /
3 Digit Security Code:

BILLING ADDRESS
Street Address
Apt.
City
State
Zip Code
Country

Choose one of the following options:

$5
$10
$15
$20
$25
$30
$50
$75
$100
Other Amount 

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Copyright © 2010 [Greater Boston/ Mattapan Technology Learning Center]. All rights reserved.
Revised: January 13, 2010