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DONATION FORM

Phone: (562) 595-6303
Fax: (562) 426-4550

Thank you for your interest in Harbor Dental Society. If you would like to consider making a contribution now, please fill in the fields below, then press "Submit My Donation."

This gift is from:

661-555-5555

Donation Types

  1. General Donation - These funds will be used were most needed.
$25 $50 $100 $250 Other

Please notify the following person that this gift has been made to Harbor Dental Society

661-555-5555

Please check that all parts of the form above have been completed and then press "Submit My Donation" only once. The confirmation page will appear shortly afterwards. Then you will be able to proceed through paypal paying via Credit Card or Paypal account (not required for payment) to complete the process.

This is a Secure Form , hosted on an SSL Server.
Any information you enter is encrypted.

Contact Information

IES Website Design & Development

You can contact us via email at , or reach us at the following address:

5401 Business Park South
Bakersfield, CA
USA