Thank you for participating in the 2021 Wild & Scenic Film Festival- A Live Virtual Event-April 22, 2021 @ 7:00pm Please select the ticket you would like to purchase. Contribution Amount Friend Ticket - $ 35.00 Patron Ticket - $ 50.00 Supporter Ticket - $ 100.00 Champion Ticket - $ 250.00 Other Amount Other Amount $ Total Amount Donor Information Title Mrs. Ms. Mr. Dr. First Name * Last Name * Email * Phone Street Address * City * State * - select State/Province - Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Country * - select Country - United States Canada Contribution Note Authorize.net (Credit Card) Card Type - select - Visa MasterCard Amex Discover Card Number * Security Code * Expiration Date * -month- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -year- 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 My billing address is the same as above Billing Name and Address Billing First Name * Billing Middle Name Billing Last Name * Street Address * City * Country * - select - United States Canada State/Province * - select State/Province - Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Postal Code * Review your contribution