MEMBERSHIP INFORMATION
       
  Please fill out below as required:
 
  PERSONAL INFORMATION
 
  First Name(*) Last Name(*)
       
Address Nº(*) City/ Town(*)
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  Zip Code(*) Fax
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MY CONTRIBUTION TO HOGAR DE CRISTO USA
WILL BE:

 
 
 
MONTHLY ANNUALLY ONE TIME ONLY
       
  Amount      
 
Other:
  Easy to remember:
US$ 30 One day's care for terminally ill patient
US$ 50 Twelve day's drug rehabilitation to a young men
US$ 70 A week's attention to a child in a community center
       
  I authorize the credit card charge on the following card:
 
  Credit Card(*)  

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Expiration Date(*) /  
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  Verification Code
Enter the address where you receive Credit Card invoice if it is different from above