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}