My commitment is as follows
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Choose one
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Determine your commitment based on this example: $2 per pair of glasses @ 100 glasses per month = $200 per month
My estimated monthly donation will be:
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I would prefer to receive a reminder for my commitment based on my monthly donation
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I would like someone to contact me to discuss this program
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Specific question(s)
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Title: (*)
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First Name: (*)
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Last Name: (*)
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Company/Practice: (*)
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Position: (*)
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Address: (*)
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City/State: (*)
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ZIP Code: (*)
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Telephone: (*)
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Fax: (*)
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Email: (*)
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Security: Please type the letters or numbers you see (*) Security: Please type the letters or numbers you see
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