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OHOT Donation Form

BILLING ADDRESS AND INFORMATION Please enter the information as it appears on your credit card billing statement. Your Name Status Student Alumni Other University Address 1 Address 2 City State --select a state-- Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip E-mail Address CREDIT CARD INFORMATION We Accept These Cards Donation Amount $ (numbers only please) Card type --select card type-- American Express MasterCard Visa Card Number Expiration Date month 1 2 3 4 5 6 7 8 9 10 11 12 year 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Security Code (MasterCard and Visa only - last 3 digits on back of card)