Toggle navigation
Menu
Support the Ron Kiene Research Scholarship!
If you have any questions about this form, please call 251-460-7032.
Gift Amount
$ 50.00
$ 100.00
$ 250.00
$ 500.00
$ 1,000.00
Other
$
*
Gift Information
Gift Type
One-time
Recurring
Frequency
Weekly
Monthly
Quarterly
Annually
On:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Starting:
Ending:
Ending:
Corporate
I am making this gift on behalf of a company
Anonymous
I would like this gift to be anonymous
Comments
Why I am giving today
Other
Personal Information
Title
Admiral
Ambassador
Brother
Capt.
Cmdr.
Dr.
Drs.
Father
General
Governor
Lt.
Major
Miss
Mr.
Mrs.
Ms.
Rabbi
Reverend
Senator
Sister
The Honorable
First name
*
Middle name
Last name
*
Country
United States
Canada
*
Address
*
City:
*
State:
<Please Select>
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
CZ
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
Mob
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
*
ZIP:
*
Phone
*
Email
*
Confirm Email
*
Payment Information
Cardholder's Name:
*
Credit Card Number:
*
Card Type:
Visa
American Express
Discover
MasterCard
*
Card Expiration:
01
02
03
04
05
06
07
08
09
10
11
12
/
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
*
Card Security Code:
*
Matching Gifts
My company will match my gift
Company
*
Tribute Information
Name:
*
First name:
Last name:
*
Type:
in honor of
in memory of
*
Description:
*
Mail a letter on my behalf to
*