IOMA Donation Form - Individual Registration

Thank you for your contribution to the Iowa Osteopathic Medical Association. IOMA is able to continue its mission because of the support of our members. As healthcare is changing, we need the combined voice of our members now more than ever before. By supporting the mission of IOMA, you are ensuring that the work of keeping our members up to date on current practices and issues continues.

We appreciate your support of IOMA by making this additional donation.

First Name *

Last Name *

Organization

Address *

City *

Cell Phone *

State *

Zip Code *

Email *

Donation Amount *

Please do not place a dollar sign ($), comma (,) or any other symbol in the donation amount blank above- this will cause the payment amount to be incorrect or to fail.

Donation Notes

By submitting this online form, I understand and agree that IOMA will have my contact details for the purpose of processing my information and ensuring full participation.

Payment Information

Amount

Payment Method

PayPal (no PayPal account login required)

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Holder Name*

Verification code*

IOMA Iowa Osteopathic Medical Association

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