Membership Form

Thank you for joining Restore 22 as a founding member
at the $500 Coffee Shop Hero level.

Please remember that you will receive your rewards when the coffee shop opens.
As that time draws nearer, we will contact you for your t-shirt size,
coffee selection and any other details.

We are working hard to reach our $100,000 goal
and will provide you with progress updates along the way.

Membership Option

Amount

Contact Information

First Name

Last Name

Address

Address 2

City

State/Province

Zip/Postal Code

Home Phone

Cell Phone

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 $500.00 to go to Restore 22 and I will donate $510.00.No. I will donate $500.00 and Restore 22 will cover the processing costs.

Credit Card Information

Card Holder Name

Card Account Number

Expiration Date

Security Code

Billing Address

Same As Above

Address

City

State/Province

Zip/Postal Code

Privacy Policy
We take precautions to protect your information. We collect credit card or bank account information, names, addresses, and other data related to your transaction when you make a payment through our site. We use this information to process your payment.

Terms/Conditions
By submitting your payment, you authorize us to charge the account above for the amount specified in the Transaction Amount field. Account information for Recurring Pledges/Monthly Giving is encrypted and stored securely via SafeSave™ for automatic processing of your future payments. Notify us at anytime if you wish to discontinue your pledge.