Welcome to Leuva Patidar Samaj of USA

Saltutation *

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True Dropdown Mr. Mrs. Miss 11

First Name *

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True TextBox Name 14

Middle Name *

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True TextBox Name 15

Last Name *

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True TextBox Name 16

Company/Organization:

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False TextBox Workplace 17

Company/Organization Matches Donations:

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False Dropdown Yes No 18

Address *

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True TextBox Address 19

City *

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True TextBox City 20

State *

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True TextBox State 21

ZipCode *

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True Numeric Zipcode 22

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False Email Email 23

Contacted via email

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False RadioButton Yes No 24

Sponsorship Donation Amount: $ *

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True TextBox Donation Amount 26

Have you donated to LPS of USA before? *

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True RadioButton Yes No 27

THANK YOU FOR YOUR SUPPORT YOUR CONTRIBUTION WILL TRULY MAKE A LASTING DIFFERENCE IN THIS ORGANIZATION

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Sponsorship Authorization Form