Associate Giving Society Thank you for your interest in the Associate Giving Society. By filling out this form you agree to a monthly credit card transaction in the amount selected below. Your charitable contribution is 100% tax deductible. Monthly Gift Amount Field Is Required Select Gift Amount: $20 $30 $50 $100 $150 Other Enter amount Designation Field Is Required Designation: Good Samaritan Fund Direct my gift to: Select a program Good Samaritan Fund Mission At Work Mobile Health Required Which campus do you primarily work at? Ascension Medical Group Ascension St. Vincent's Riverside Ascension St. Vincent's Southside Ascension St. Vincent's Clay County Employee ID Billing Information First Name: Last Name: Street 1: City: State/Province: AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming AS - American Samoa FM - Federated States of Micronesia GU - Guam MH - Marshall Islands MP - Northern Mariana Islands PR - Puerto Rico PW - Palau VI - Virgin Islands AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon None Required ZIP/Postal Code: Email Address: Yes, I'd like to receive email updates from this organization. Payment Information Credit Card Information: Credit Card Type: Credit Card Number: Expiration Date:Select month of credit card Select Expiration Year 01 02 03 04 05 06 07 08 09 10 11 12 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 CVV Number: What is this? Process ABOUT SSL CERTIFICATES
