Recurring Sponsorship Payment | Michigan Psychoanalytic Institute

Sponsorship Details

*This information is required

Contact Name*

First Last

Select Sponsorship Type*

Recurring (Monthly) Payment Amount*

Note: 1st payment will be debited on day you make payment, you must contact office to change the date of the next payment will occur.

# Of Times You Wish Payment To Recur*

Please Print Exactly How You Would Like To Be Recognized In The Event Program

Please Check Here If You Prefer To Remain Anonymous

Solicitor Name

*This information is required

Donation Amount (Optional)

Email*

Phone*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Secure Credit Card

Card Holder*

Card Number*

Card Expiration*

Card CVV*

Would you like to add a 3.5% convenience fee to help cover the costs of processing?*

Convenience Fee

$0.00

TOTAL

$0.00

CAPTCHA