MODentPAC Donation Form

Complete this form to make a MODentPAC donation. To learn about PAC giving levels or complete a PDF giving form go to modental.org/pac.

Billing Information

Cardholder first name *

Cardholder last name *

Billing Address *

Billing City *

Billing State *

Billing Zip *

Phone number *

Email *

Today's payment amount *

Recurring Information

Make this a recurring transaction

In addition to the above amount today, you will be charged the above amount on the 15th every month starting on the next applicable future date.

Cancellation Policy +

Cancellations/Changes/Receipts: Please contact the MDA if you wish to cancel or change your recurring giving amount. Unless notified, we will continue to charge your card in the amount specified each month. When your credit card is charged for the first time, and again on each recurring date, you will receive an email receipt from receipts@safewebservices.com.

I guarantee that I am the legal cardholder for this credit card, that I am legally authorized to enter into this billing agreement.

Save my payment information for future use.

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