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

IOMA has transitioned to our own secure payment gateway. As a result of this change, a 3.25% convenience fee will apply to all credit card payments to help IOMA cover the cost of accepting credit cards. Please let us know if you have any questions. We appreciate your continued support of IOMA.

Amount

Payment processing fee

Gross Amount

Payment Method

Secure Payment Processing

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Holder Name*

Captcha*

IOMA Iowa Osteopathic Medical Association

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