Name: {Name (First):2.3} {Name (Last):2.6}
Address: {Address (Street Address):3.1} {Address (Address Line 2):3.2}
City: {Address (City):3.3}
State/Province: {State:22}{Province/Territory:24}{Province/Region:25}
Postal Code: {Zip Code:23}{Postal Code:26}
Country: {Country:108}
Phone: {Phone:53}
Email: {Email:5}
Member Number: {Member Number:102}
Membership Level: {Donation amount: (All donations are charged in U.S. dollars):59}{Donation amount: (All donations are charged in U.S. dollars):65}
Premium: {Thank You Gift?:112}{Thank You Gift?:111}{Thank You Gift?:113}{Thank You Gift?:95}{Thank You Gift?:103}
Total Donation to be Charged: {Total:93}
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