Candidate Fee Donation - Birmingham Vida Nueva

Please select Upcoming Weekend:*

Please select candidate for Weekend:*

Name of Candidate*

First Last

Donor's Name*

First Last

Donor's Email*

Donor's Phone*

Donate Full Candidate Fee

Price: $85.00 Quantity:

Donation Amount

If you would like to donate an amount other than the full fee of $85.00 please list below.

Total fee paid:

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Name

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