Rural Heritage Farm Membership Donation Form

Donation Amount:

$ 35.00

Choose Your Donation Amount:

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Terms

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Enter your contact information

First Name *

Last Name *

Provide your First Name as you would prefer your membership or donor listing to read (i.e., Dick and Jane)

Membership Directory Preference:

Include me

Only include my name in the directory

Exclude me entirely from the directory

Email Address *

Phone Number(s):

Mailing Address

Country *

Address 1 *

Address 2

City *

State *

Zip / Postal Code *

Donation Total: $35.00

Credit Card Info

This is a secure SSL encrypted payment.

Card Number *

CVC *

Cardholder Name *

Expiration *