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			<h1 class="article-header__title js-article-title js-page-title">Chai Club Donation Form</h1>
		
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                <legend class="style12">Donation Information</legend>
<table border="0" cellspacing="0" cellpadding="10" width="98%" align="center">
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<strong>
<span class="style4">I would like to make a contribution of:</span></strong></td>
</tr>
<tr>
<td class="style8" colspan="3">
<input tabindex="1" checked type="radio" name="Donation_Amt" value="18" style="vertical-align: middle; margin-top: 0px; margin-left: 4px; padding: 0px;"><span style="font-size: 13px;">
<span style="font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">$18</span><span style="font-family: Arial; line-height: 25.2000007629395px; color: rgb(255, 255, 255); background-color: rgb(255, 255, 255);">iii</span><input tabindex="1" type="radio" name="Donation_Amt" value="36" style="vertical-align: middle; margin-top: 0px; margin-left: 4px; padding: 0px;"><span style="font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">$36<span style="color: rgb(255, 255, 255); font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">iii</span><span style="color: rgb(255, 255, 255); font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">i</span></span><input tabindex="1" type="radio" name="Donation_Amt" value="54" style="vertical-align: middle; margin-top: 0px; margin-left: 4px; padding: 0px;"><span style="font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">$54<span style="color: rgb(255, 255, 255); font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">iii</span></span><input tabindex="1" type="radio" name="Donation_Amt" value="72" style="vertical-align: middle; margin-top: 0px; margin-left: 4px; padding: 0px;"><span style="font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">$72<span style="color: rgb(255, 255, 255); font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">iii</span></span><input tabindex="1" type="radio" name="Donation_Amt" value="180" style="vertical-align: middle; margin-top: 0px; margin-left: 4px; padding: 0px;"><span style="font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">$180<span style="color: rgb(255, 255, 255); font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">iii</span></span><input tabindex="1" type="radio" name="Donation_Amt" value="1800" style="vertical-align: middle; margin-top: 0px; margin-left: 4px; padding: 0px;"><span style="font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">$1800<span style="color: rgb(255, 255, 255); font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">iii</span>Other Amount: $ </span><input tabindex="2" class="light active" size="7" required="true" name="other donation amount" value=".00" type="text" style=""><span style="font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">  US</span><img alt="" width="1" height="5" src="https://chabadwesthempsteadorg.clhosting.org/images/global/spacer.gif" style="font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);"><span style="font-family: Arial; line-height: 25.2000007629395px; background-color: rgb(255, 255, 255);">                                                                                     </span></span></td>
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<span style="font-family: Arial; line-height: 25.2000007629395px; font-size: 13px; background-color: rgb(255, 255, 255);"> Please charge the above amount to my credit card each month for the next twelve months.</span></td>
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<strong>
<font size="2" face="Tahoma">Optional Dedication</font></strong></td>
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<input tabindex="4" type="radio" name="Memory" value="In memory of"><span style="font-size: 13px;"><strong>In Memory of</strong>                                                                                       <br>
                        Make a donation in memory of a deceased family member or friend. </span></td>
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<span style="font-size: 13px;"><input tabindex="4" type="radio" name="Memory" value="In honor of"><strong>In Honor of</strong>                                                                                         <br>
                        Make a donation in honor of someone or to celebrate a joyous occasion. </span></td>
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<td class="style8" colspan="3">
<span style="font-size: 13px;">Details:<br>
</span><textarea name="dedication details" tabindex="5" required="false" cols="77"></textarea></td>
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<strong>My Info</strong></td>
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<td class="style4" width="33%"><span style="font-family: Arial; font-size: 11px; background-color: rgb(255, 255, 255);">Title</span><br style="background-color: rgb(255, 255, 255);">
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<option value="Mr.">Mr.</option>
<option value="Mrs.">Mrs.</option>
<option value="Mr &amp; Mrs.">Mr &amp; Mrs.</option>
<option value="Dr.">Dr.</option>
<option value="Dr. &amp; Mrs.">Dr. &amp; Mrs.</option>
<option value="Drs.">Drs.</option>
<option value="Rabbi">Rabbi</option>
<option value="Rabbi &amp; Mrs.">Rabbi &amp; Mrs.</option>
<option value="The Honorable">The Honorable</option>
</select></td>
<td class="style4" width="35%"><span class="style1" style="color: rgb(9, 38, 51); font-family: tahoma; font-size: 11px; background-color: rgb(255, 255, 255);">First Name</span><span style="font-family: tahoma; font-size: 11px; background-color: rgb(255, 255, 255);">          Last name</span><br style="font-family: tahoma; font-size: 11px; background-color: rgb(255, 255, 255);">
<input type="text" name="x_first_name" size="7" tabindex="7" required="true"><input type="text" name="x_last_name" size="7" tabindex="7" required="false"></td>
<td class="style4" width="32%"><span style="font-family: tahoma; font-size: 11px; background-color: rgb(255, 255, 255);">Email </span><br style="font-family: tahoma; font-size: 11px; background-color: rgb(255, 255, 255);">
<input tabindex="8" size="9" required="true" name="email" type="text" style="width: 140px; height: 22px;"></td>
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<td class="style4"><span style="font-family: tahoma; font-size: 11px; background-color: rgb(255, 255, 255);">Address </span><br style="font-family: tahoma; font-size: 11px; background-color: rgb(255, 255, 255);">
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<td class="style4"><span style="font-family: tahoma; font-size: 11px; background-color: rgb(255, 255, 255);">City/State/Zip </span><br style="font-family: tahoma; font-size: 11px; background-color: rgb(255, 255, 255);">
<font size="2" face="Tahoma" style="background-color: rgb(255, 255, 255);">
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                              </td>
<td class="style4"><span style="font-family: tahoma; font-size: 11px; background-color: rgb(255, 255, 255);">Home Phone </span><br style="font-family: tahoma; font-size: 11px; background-color: rgb(255, 255, 255);">
<font size="2" face="Tahoma" style="background-color: rgb(255, 255, 255);">
<input tabindex="13" size="23" required="false" name="x_phone" type="text" style="width: 140px; height: 22px;"></font>
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<tr>
<td class="style4" colspan="2">This is my: <input tabindex="15" type="radio" name="address type" value="home">Home  <input tabindex="15" type="radio" name="address type" value="business"> Business Address</td>
<td class="style4"> </td>
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<td class="style5" bgcolor="#EEE4CC" colspan="3">Payment Info</td>
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<span class="style8">Charge Amount <br>
<input tabindex="100" size="11" required="false" style="width: 140px; height: 22px" name="x_amount" type="text"></span></td>
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<span class="style4" style="font-family: tahoma; font-size: 11px">Card Type <br>
<select tabindex="101" style="width: 140px" name="x_card_type">
<option value="Please Select" selected>Please Select</option>
<option value="Visa">Visa</option>
<option value="Mastercard">Mastercard</option>
<option value="American Express">American Express</option>
<option value="Discover">Discover</option>
</select></span></td>
<td width="33%">
<span class="style4" style="font-family: tahoma; font-size: 11px">Card Number <br>
<input tabindex="102" maxlength="16" size="13" required="false" style="width: 140px; height: 22px" name="x_card_num" type="text"></span></td>
</tr>
<tr>
<td>
<span class="style4" style="font-family: tahoma; font-size: 11px">Expiration Date <br>
<select tabindex="103" month="" style="width: 75px" name="x_exp_month">
<option value="Month" selected>Month</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select><select tabindex="104" style="width: 65px" name="x_exp_year">
<option value="Year" selected>Year</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
<option value="2029">2029</option>
<option value="2030">2030</option>
<option value="2031">2031</option>
<option value="2032">2032</option>
<option value="2033">2033</option>
<option value="2034">2034</option>
<option value="2035">2035</option>
</select></span></td>
<td>
<span class="style4" style="font-family: tahoma; font-size: 11px">Card Code <br>
<input tabindex="105" maxlength="4" size="11" required="false" style="width: 140px; height: 22px" name="x_card_code" type="text"></span></td>
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<span class="style8">Comments <br>
<input tabindex="106" size="13" required="false" style="width: 140px; height: 22px" name="comments" type="text"></span></td>
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<input tabindex="200" type="radio" name="Receipt" value="email" style="vertical-align: middle; margin-top: 0px; margin-left: 4px; padding: 0px;"><span style="font-size: 13px;"><span style="font-family: arial; background-color: rgb(255, 255, 255);"> You may acknowledge my gift to my email address</span><br type="_moz">
</span></td>
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<span style="font-size: 13px;"><input tabindex="200" type="radio" name="Receipt" value="mail" style="vertical-align: middle; margin-top: 0px; margin-left: 4px; padding: 0px;"><span style="font-family: arial; background-color: rgb(255, 255, 255);"> Please acknowledge my gift by mail to the above street address.</span><br type="_moz">
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<span style="font-family: arial; font-size: 13px; background-color: rgb(255, 255, 255);"><input type="checkbox" name="contact me to discuss further giving opportunities" tabindex="209"> Please contact me to discuss additional giving opportunities.</span></td>
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<span style="font-size: 13px;"><strong>Please click submit only once.</strong>                    <br>
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