Pledge-A-Picket Pledge Form for ACCON

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Please provide the following contact information:
First Name
Last Name
Middle Initial
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL
Please provide the following ordering information:
Item#   DESCRIPTION                                                            Pledge  Monthly Limit
1        Clinic Picketer, Adult, each per day              
2 Clinic Picketer, Children 14 and under, each per day
3 Clinic Grotesque Poster/Sign, each per day
4 Clinic appearance of so called "Truth-Truck" per day
5 Home Picketer, Adult, each per day
6 Home Picketer, Children 14 and under, each per day
7 Home Grotesque Poster/Sign, each per day
8 Home appearance of so called "Truth-Truck" per day
         PLEASE LIMIT MY TOTAL MONTHLY DONATION TO: 
 
Select the following option for payment:

Please bill me at the end of each month.
I will check this site and pay online.
I will check this page and mail my check.


Send mail to webmaster@Pledge-A-Picket.org with questions or comments about this web site.
Copyright 2009 Pledge-A-Picket.org
Last modified: 08/30/09