Massachusetts Association of Physician Associates

Donations - Secure Online Donation Form

Campaign/Fund Information
Campaign/Fund *	MAPA PAC Fund

Donation Information

Donation Amount *

NOTE:

The maximum donation amount is $500.00

Payment Method *

Check/Money Order

Credit Card

Donation Type *

One-Time Donation
Recurring Monthly Donation (until cancelled)
Split this Donation into Monthly Payments

Number of Payments *

Occupation *

Place of Employment *

I am at least eighteen years old *

Contribution Characteristics *

This contribution is made from my own funds, and funds are not being provided to me by another person or entity for the purpose of making this contribution.

US Citizen *

I am a U.S. citizen or lawfully admitted permanent resident (i.e., green card holder).

Personal Card *

I am making this contribution with my own personal credit card and not with a corporate or business credit card or a card issued to another person.

Donor Comments

Donor Information

First Name *
Middle Name
Last Name *
Suffix
Organization
Email *
Address *
Address Cont.
City/Town *
Country *
Location	(Reset)
Postal Code*
Phone *

Billing Information
[ Click here if billing address is the same as donor address ]
Name on Card *
Card Type *
Card Number *
Card CVV Num *	What is this?
Exp. Date *	/
Organization
Address *
Address Cont.
City/Town *
Country *
Location	(Reset)
Postal Code*
Billing Phone *

The Cardholder stated above has authorized this payment. If this payment is part of a recurring series of payments, the Cardholder understands the terms and amounts of those recurring payments, and authorizes payment for each of them. Cardholder consent will expire once all scheduled recurring payments have been processed, or if all future recurrences are cancelled. The Cardholder acknowledges that specific payment dates may vary. Examples include, but are not limited to: payment dates falling during weekends, holidays, or during system outages. In order to facilitate the processing of those recurring payments, stored credentials will be used. Those stored credentials will only be used to process payments that are part of this series of recurrences. In order to use those stored credentials for any other payment, Cardholder re-authorization will be required. In the event that a consent agreement must be modified, the new agreement will be sent to the email address associated with the invoice.

The Cardholder understands the terms and authorizes the payment(s).

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