Name

First

Last

Address

Address 1

Address 2

City

State

Postal Code

Country

Phone Number

Email

Please select the stepping stone option(s) that you prefer:*

4" X 8" Stepping Stone ($280)

8" X 8" Stepping Stone ($380)

4" X 8" Stepping Stone + Minibrick ($288)

4" X 8" Stepping Stone + Minibrick ($391)

Donation of your choice

Which Form of Payment Do You Prefer?*

Name as it appears on the Credit/Debit Card*

Credit/Debit Card Number*

Expiration Date (mm/yy)

Total Donation

Would you like to make a one time payment, or break it into monthly payments?

One Time Payment

Multiple Payments

If you are choosing automatic monthly payments, on what date would you like the first payment to be made?

For multiple payments, how many months would you like to have the automatic payments take place?

By checking this box, you are indicating that you would like for us to set up an automatic payment from your credit/debit card*

Please charge my credit/debit card according to my preferences.

Thank you for your generosity. We will contact you via email to confirm the details of this transaction.

May God bless you,

Kern Seventh-day Adventist Elementary School

Credit Card Order Form