Sample Page

Theater Alliance

This is the payment page header where you can write something compelling.

Contributor

First Name

Last Name

Street Address

City

State

ZIP

Phone

Legal Compliance

I confirm that the following statements are true and accurate:

I have read and accept the Democracy Engine Terms of Service, Privacy Policy, and Refund Policy.
I am at least eighteen years old.

Recipients & Amounts

Theater AllianceTax Deductible
$
TOTAL
$

Payment method

Credit Card Electronic Check

Credit Card

Card Number Four_cards

Expiration Date

Security Code (CCV)

Electronic Check

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

By clicking the donate button below, I acknowledge that my payment is being made to Democracy Engine, who accepts the responsibility of distributing the funds to my designated recipient(s) in accordance with applicable campaign finance laws. My card or bank statement will show a payment to “Democracy Engine” or “DEMENG” 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. Democracy Engine will charge each recipient an applicable service fee.