1. Title Mr. Ms. Mrs. Mr. & Mrs. Dr.

   First nameRequired

   Last name Required

2. Address Required

3. City Required

   State Required Alabama Alaska Arizona Arkansas Armed Forces (AA) Armed Forces (AE) Armed Forces (AP) California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

   Postal code Required Postal code Required

   Country Required Select a country

   State/Province Please choose one (int'l state/province)

   I have a non-U.S. address

   I have a U.S. address

4. Email (will receive automatic acknowledgment with gift details; do not enter honoree's email here)Required

   Telephone

   I would like this gift to remain anonymous.

1. First nameRequired

   Last name Required

2. Address Required

3. City Required

   State Required Alabama Alaska Arizona Arkansas Armed Forces (AA) Armed Forces (AE) Armed Forces (AP) California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

   Postal code Required Postal code Required

   Country Required Select a country

   State/Province

   I have a non-U.S. address

   I have a U.S. address

Gift (one-time or recurring)

Pledge (first installment required)

This gift is made in honor or memory of someone.

1. Required Gift in honor of Gift in memory of

   Name of person being honored or remembered Required

2. Please notify the following person about my gift (amount will not be mentioned).

   Full name, address, city, state/province and postal code

1. Gift code (if applicable)

   I am a Kiwanis-family member.

   Name and location of Kiwanis-family club

   Kiwanis-family club key number, if known

   I do not want any benefits for my gift.

   Comments

1. Visa MasterCard AMEX Discover

2. Credit card number

   Card security code

   Expiration date 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027

3. Routing Number

   Bank Account Number