Donation Form

Thank you for making a difference in the lives of the survivors we serve!

* Required Fields

Donation
Amount
Type of Donation	One Time Donation Recurring Donation
Frequency
Campaigns
	Complete the following fields if this gift is a tribute. (optional)
Type of Tribute
Tribute's First & Last Name
	*Please send acknowledgement to:*
Title (Mr/Mrs/Ms)
First Name
Last Name
Address
Address 2
City
State/Province
Zip/Postal Code
Email
Cell Phone

Contact Information
* First Name
* Last Name
Company Name		Title
* Address		* City
* State/Province		* Zip/Postal Code
* Phone		Work Phone
* Email		How did you hear about The Safe Center?
I would like to receive future emails from TSCLI

Help Us Cover Costs
Simply leave "Yes!" checked below to ensure that 100% of your intended donation is available for our mission.
Yes! I want $0.00 to go to The Safe Center LI and I will donate $0.00. No. I will donate $0.00 and The Safe Center LI will cover the processing costs.

Credit Card Information
* Card Holder Name
*
* Card Account Number
Expiration Date
* Security Code The 3 or 4 digit Security Code (CVV2) can be found on the back of your credit card. For American Express, the Security Code (CID) can be found on the front of the card.

Billing Address
Same As Above
* Address
* City
* State/Province
* Zip/Postal Code
* Email

Privacy Policy
We keep your personal information private and secure. When you make a payment through our site, you provide your name, contact information, payment information, and additional information related to your transaction. We use this information to process your payment and to ensure your payment is correctly credited to your account.