Membership Dues Payment

Minimum $420 for 2020 dues

Contributor

First Name

Last Name

Street Address

City

State

ZIP

Country

Phone

I confirm that the following statements are true and accurate:

I understand that my payment is being made to Democracy Engine, who accepts the responsibility of distributing the funds to my designated recipient(s). My card or bank statement will show a payment to “Democracy Engine” and if there are any issues or discrepancies with the payment or I wish to revoke the payment, I can contact Democracy Engine at support@democracyengine.com.
I am at least eighteen years old.
I have read and accept the Democracy Engine Terms of Service, Privacy Policy, and Refund Policy.

Purpose of the Contribution

if other, please provide purpose

Payment method

Credit Card Electronic Check

Card Number Four_cards

Expiration Date

Security Code (CCV)

Account Type

Checking Savings

Routing (Bank) Number(omit any dashes or spaces)

Retype Routing Number

Account Number(omit any dashes or spaces)

Retype Account Number