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2. Donation Amount*
   -- Select One --One Star - $500 to $2,499Two Stars - $2,500 to $4,999Three Stars - $5,000 to $9,999Four Stars - $10,000 to $14,999Five Stars - $15,000 or more
3. Please indicate exact donation amount*

   Donations exceeding $25,000 will receive a special designation.

5. Paver Information
7. Line One (first name)*

   First names of family or initials, part of business or organization name. Please adjust name to fit the allotted space (22 characters).

9. Line Two (last name)*

   Last name of family, business or organization name. Please adjust name to fit the allotted space (22 characters).

11. Contact Information
13. Name*
15. Address*
17. City*
18. State*
20. Zip Code*
21. Phone (used only for questions)*
23. Email (used for questions and ACC/AVM news updates)*
25. Important: Before submitting this form, verify that all information is correct. Once submitted this information cannot be changed.

29. 1. If the form does not redirect after submission, please visit this page to make payment.

       Please complete this transaction and the payment process through PayPal now. Click the "Pay with Debit or Credit Card" button. 

       Once payment is complete, you will receive an email within a week finalizing how the veteran's information will appear on the paver.

31. By checking this box, you agree to receive SMS text messages from Anthem Community Council. Reply STOP to Opt-Out at any time. Messages and data rates may apply. Message frequency will vary. You agree to our Terms and Conditions and our Privacy Policy & Disclaimer.*

    1. Agree

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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

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