Purchase a Paver Form -

Purchase a Paver

"*" indicates required fields

Purchase a Paver*

Paver - $250

Paver (Non-Profit) - $150

Paver HHLI Employee

Quantity*

You can purchase up to 10 pavers per transaction.

Paver# 1

Paver# 1 - Line 1*

(max 14 characters incl. spaces)

Paver# 1 - Line 2*

(max 14 characters incl. spaces)

Paver# 1 - Line 3*

(max 14 characters incl. spaces)

Paver# 2

Paver# 2 - Line 1*

(max 14 characters incl. spaces)

Paver# 2 - Line 2*

(max 14 characters incl. spaces)

Paver# 2 - Line 3*

(max 14 characters incl. spaces)

Paver# 3

Paver# 3 - Line 1*

(max 14 characters incl. spaces)

Paver# 3 - Line 2*

(max 14 characters incl. spaces)

Paver# 3 - Line 3*

(max 14 characters incl. spaces)

Paver# 4

Paver# 4 - Line 1*

(max 14 characters incl. spaces)

Paver# 4 - Line 2*

(max 14 characters incl. spaces)

Paver# 4 - Line 3*

(max 14 characters incl. spaces)

Paver# 5

Paver# 5 - Line 1*

(max 14 characters incl. spaces)

Paver# 5 - Line 2*

(max 14 characters incl. spaces)

Paver# 5 - Line 3*

(max 14 characters incl. spaces)

Paver# 6

Paver# 6 - Line 1*

(max 14 characters incl. spaces)

Paver# 6 - Line 2*

(max 14 characters incl. spaces)

Paver# 6 - Line 3*

(max 14 characters incl. spaces)

Paver# 7

Paver# 7 - Line 1*

(max 14 characters incl. spaces)

Paver# 7 - Line 2*

(max 14 characters incl. spaces)

Paver# 7 - Line 3*

(max 14 characters incl. spaces)

Paver# 8

Paver# 8 - Line 1*

(max 14 characters incl. spaces)

Paver# 8 - Line 2*

(max 14 characters incl. spaces)

Paver# 8 - Line 3*

(max 14 characters incl. spaces)

Paver# 9

Paver# 9 - Line 1*

(max 14 characters incl. spaces)

Paver# 9 - Line 2*

(max 14 characters incl. spaces)

Paver# 9 - Line 3*

(max 14 characters incl. spaces)

Paver# 10

Paver# 10 - Line 1*

(max 14 characters incl. spaces)

Paver# 10 - Line 2*

(max 14 characters incl. spaces)

Paver# 10 - Line 3*

(max 14 characters incl. spaces)

Other Notes or Comments

Donor Information

Name*

First Last

Company (if a corporate donation)

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Email*

Billing Information

Address

Is the Billing address the same as the mailing address?

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Ensure that Harmony Healthcare Long Island receives 100% of the value of my donation.

Price: $0.00

What does this mean?

Grand Total

Purchase a Paver

Paver# 1

Paver# 2

Paver# 3

Paver# 4

Paver# 5

Paver# 6

Paver# 7

Paver# 8

Paver# 9

Paver# 10

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