TCA

Donation Form

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Personal Information

First Name

Last Name

Address 1

Address 2

City

State

Zip

Phone

Donation

Please enter donation amount(s) in the fields below for the program(s) you wish to support

Chiropractic Development Initiative (CDI)/Legal Defense

TCA Political Action Committee (TCA PAC)

Please have a staff member contact me to set up autodraft. I want to donate:

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Payment Type

NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.

Credit Card Information

Credit Card Type MastercardVisaDiscoverAmex

Credit Card Number

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