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NHCA Care PAC Contribution Form - 2022

"*" indicates required fields

Step 1 of 4

25%

Contributor Information

Recognition Name*
Address*

Contribution Information

Contribution Recognition*

Please note:

If you are an individual, you can choose a Club Membership based on your contribution level. This is available to member facility employees, corporate office staff, owners, as well as individual members. Proprietary member facilities can participate at a suggested $2 per bed or more. Non-profit or government facilities should consult with a tax professional prior to contributing.
Do you want to donate as a proprietary member facility using a per bed contribution?*

Proprietary Member Facility Per Bed Contribution

Contribution suggested at least $2 per bed.
Please enter a number greater than or equal to 1.

Member Facility/Company Contribution

Individual Contribution

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Your Contribution Level is:

Contributor Club

Your Contribution Level is:

Leadership Club

Your Contribution Level is:

Advocate Club

Your Contribution Level is:

Capitol Club

Your Contribution Level is:

Silver President’s Circle

Your Contribution Level is:

Gold President’s Circle

Your Contribution Level is:

Platinum President’s Circle

Contribution Levels

President’s Circle
● Platinum President’s Circle $5,000 or more
● Gold President’s Circle $2,500-$4,999
● Silver President’s Circle $1,000-$2,499
Capitol Club $500-$999
Advocate Club $200-$499
Leadership Club $50-$199
Contributor Club $10-$49

Contributor Category*
Please select the contributor category that best describes you.
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Contribution Level

Review Your Selections

Click "Previous" to make changes. Click "Submit" to process your registration(s). {all_fields} After clicking on "Submit", please wait. It could take a bit to process. You will be redirected to a new screen when the transaction has been completed.

Payment Information

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Payment Type*

For recurring donations, please contact NHCA at 402-435-3551.

Credit Card Information

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The Cardholder address the same as the previous address in this form?
Cardholder Address*
Credit Card*
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Expiration Date
 
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