LifeCare Alliance T-Shirt Order Form

To purchase a LifeCare LifeCare Alliance T-Shirt please fill in the information below. When your purchase is complete please read your confirmation for shipping information.
Donation Levels 
  Level Range
    Ohio- Let's Do Lunch T-Shirt 
$15 and up
* required information
Donation
Donation Amount
:* $
Donor Information
PLEASE FILL IN YOUR SHIRT SIZE IN THE NOTES FIELD.
First Name:*
Last Name:*
Company Name:
Email:*
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Phone:
Business Phone:
Cell Phone:
Notes:*
Payment Information
Payment Method
:*
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Credit Card Type:*
                  
Credit Card Expiration:*
Billing Information
If the billing information is the same as the contact information check this box.
If not please fill out the information below:
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State:
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Country:*
By clicking Submit,
your credit card will be processed