Donation - Southern Medical Association

"*" indicates required fields

Name*

First Middle Last Suffix

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Amount*

Enter Custom Amount

Customize Your Gift

Name Your Scholarship (Not Required)

Example: The John Doe Scholarship OR The ACME Oil Company Scholarship. *Named Award/Scholarship only applies to donations of $5000 (total annual give) or more. Once decided upon, we will send you all of the pertinent info for the recipient(s).

Credit Card*

Card Details

Cardholder Name

Consent*

Consent for One-time Payment

I understand that SMA will execute a one-time charge to the card or payment method provided within this form on the date listed herein.

Total

Thank you so much.

The Southern Medical Association is a Non Profit Organization.

Your support is critical to our success.