CARDHOLDER INFORMATION *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

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I understand that a representative of DVCAI will contact me for credit card information to charge my card. I AUTHORIZE DIASPORA VIBE CULTURAL ARTS INCUBATOR TO CHARGE THE DONATION AMOUNT INDICATED ABOVE FOR GIVE MIAMI DAY 2023. THIS AUTHORIZATION EXPIRES AFTER NOVEMBER 16, 2023. *

YES

NO

Name *

First Name

Last Name