User:Sj/donations

STEP 1.' Fill out the secure online giving form

• Data Privacy Information
• Secure Server Information

* = required fields

Designation*

You have chosen to give your gift to (note: you can further specify your designation below):	Amount	Joint Gift with Spouse/Partner?
[dropdown options]	[textfield]	[checkbox]
If you would like to make additional gifts, please select additional designations:
[dropdown options]	$[textfield]	[checkbox]
[dropdown options]	$[textfield]	[checkbox]
[dropdown options]	$[textfield]	[checkbox]
	$[textfield]	Note: Your total gift will be calculated automatically. If JavaScript is turned off in your browser you will not see a total until you submit this form
Would you like to designate this gift for a: (dropdown): Department/ Field of Research/ Honorary payment/ Pledge payment/ Memorial gift/ Other
Additional information (if necessary): (textfield) [prefilled with a referrer-code, or a 'gift-type' code, for instance.

[form]

Personal Information
First name:*	[textbox]
Middle name:	[textbox]
Last name:*	[textbox]
Spouse/Partner first name: (if this is a joint gift)	[textbox]
Spouse/Partner middle name:	[textbox]
Spouse/Partner last name:	[textbox]
Address:*<br\> So we may send you a confirmation letter [radio buttons: Home Business]	[textbox]
Street:*	[textbox]
City:*	[textbox]
State/Province:* Required only for U.S., Canada, and Mexico [dropdown for state/pvnce]	Other: [textfield]
Zip/Postal code:*	[textfield]
Country: [dropdown for country]	Other: [textfield]
Contact Information:* Please provide us with your home or work e-mail so we may contact you if we have questions about your gift.	[textfield]
E-mail:	[textfield]
Is this your [radio: ()home or ()business] e-mail address?
If you prefer that we contact you by phone, please provide a phone number.
Home phone:	[textfield] (area code/country code)
Business phone:	[textfield] (area code/country code)
Method of payment:*	[radio ()Visa ()Master Card ()American Express]
Credit card number: (please use spaces between numbers: e.g. xxxx xxxx xxxx)	[textfield]
Expiration date:	[textfield]
Name as it appears on credit card if different from above:	[textfield]
Permission to publish:	[radio () You may publish my/our name(s) in Wikimedia donor rolls. () I/we wish to remain anonymous.]
Matching funds:	I (or my spouse) work for a matching gift company. [radio: Yes No] If yes, name of company: [textfield]
New: check our online directory of companies who match gifts to see if your employer is among them. Then submit appropriate paperwork to: Gift Processing, The Wikimedia Foundation, (address).
Are you a Wikimedia editor/member?	(radio: Yes No)
If yes, in which projects?	[selectbox]
Active handles:	(textfield)
How did you find this page?	[radio: Referred by solicitation letter | Referred by a phone campaign | Browsing the Web on my own | E-mail | Other]
Would you like to receive our quarterly newsletter via email?	(radio: Yes No)
Via postal mail?	(radio: Yes No)

[/form]