W3R Lapel Pin Donation Form
With questions about donation and receiving a pin, please email Julia Diddell. Our PayPal online option is not currently available.
W3R-NJ, c/o Julie Diddell
411 Elm Street
Westfield, NJ 07090
Name:____________________________________________________
Street:____________________________________________________
City:____________________________ State:_____ Zip:_______
Number of Pins:____ x $15.00 Check Amount:____________
Or, you can charge your Visa __ MC __ AmEx __ Discover __ card.
Credit Card Number: _______________________ Exp. Date: ______
Card Verification Number: _______ (On the back of card next to the last four digits)
Phone Number: _________________________
|