Drug and Alcohol Testing Industry Association
1325 G Street, NW, Suite 500#5001
Washington, DC 20005
800.355.1257 (p)
202.315.3579 (f)
datia.org
info@datia.org

Marijuana Outreach Fund Donation Form

Donations are not deductible as tax-exempt.


Personal Information

Title

Your Name

Company Name

Address

City

State

Zip

Phone

Email

Website

How should your donation be recognized?

Company Name

Individual Name This donation has been made on behalf of:


Note: DATIA will contact this person to inform them of your donation on their behalf.


Why are you donating?

Donor Level

  • Supporter ($1-$999)
  • Benefactor ($1,000 - $2,499)
  • Fellow ($2,500 - $4,999)
  • Partner ($5,000+)

Payment

Donation Amount:

Payment Type:

VISA

Master Card

American Express

Card #

Name on Card

Expires