IOMA PAC Donations - Individual Registration

Please enter information in the form below to process registration for event IOMA PAC Donations.

First Name *

Last Name *

Clinic/Office Name *

Address *

City *

State *

Zip Code *

Phone *

Email *

PAC Donation Amount *

$1,000

$500

$250

$200

$150

$100

$50

Contributions to IOPAC can be made from a personal account or credit card but cannot be made from a corporate account or corporate credit card. All contributions are voluntary and are not tax deductible.

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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