Leva Patidar Samaj of Houston
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Leva Patidar Samaj of Houston (LPSH) COVID-19 Donation Drive
Donation Form
Name:
Email Id:
Address:
City:
State:
Zip Code:
Phone Number:
Gaam:
Amount to Donate:
$25
$51
$101
Other
Credit Card Type:
Select Card
Visa
Master Card
Discover
American Express
Name on Card:
Card Number:
Expiry Month:
MM
01
02
03
04
05
06
07
08
09
10
11
12
Expiry Year:
YYYY
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
CVV:
Billing Zipcode:
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