On-line Donation Form

( * indicates a required field )
* Name:      
Title / Position: 
Org. Affiliation: 
* Address:      Home    Work
 
* City:        State / Prov.:  
* Postal Code:             * Country:  
* E-mail: 
Home Phone:      Home FAX:  
Work Phone:       Work FAX:  
 

   Your donation to ACOSA will help subsidize memberships and event fees for students, retirees,
   unemployed and low-income members, as well as Journal and ACOSA operating expenses. If you
   would like to have your donation used to support a specific activity within ACOSA, please indicate
   in the "Comments, Special Instructions" box below. Under the U.S. tax code ACOSA is a 501(c)(3)
   corporation. Donations made under this section of the tax code are normally deductible from federal
   income taxes as a charitable donation. However you should check with your accountant or the
   Internal Revenue Service on the deductibility of your donation.

   Donation Amount:  

   Comments, Special Instructions...
   
 

   Payment Information:
   Make U.S. check or money order payable to ACOSA and mail to address below.
   International subscriptions only payable by credit card or money order in U.S. dollars (USD).
   Your on-line transaction is protected by a Secure Socket Layer (SSL) connection with 256-bit
   encryption.

Payment Type:    Check / M.O.    MasterCard    Visa    AMEX    Discover
Card Number:  
(ex.: 1111222233334444)    		      Exp. Date:    / 
Amount:                       Verification No.:    What's This?
 
    Use Name & Address Above
Card Holder Name:  
Address: 
City:      State / Prov.: 
Postal Code:             Country: 
 
*** Print a copy of this form for your records before submitting. ***
 
                    
 
Mail Check To:   ACOSA
20560 Bensley Avenue
Lynwood, Illinois 60411 USA
 
Federal EIN:   36-4062716
Phone:   708-757-4187      FAX:  708-757-4234
E-mail:   member@acosa.org