IOMA Donation Form - Individual Registration

Thank you for your contribution to the Iowa Osteopathic Medical Association. IOMA is able to continue its mission because of the support of our community.

We appreciate your support of IOMA by making this additional donation.

First Name *

Last Name *

Degree *

Email *

Company/Clinic/Organization

Address

City

State

Zip Code

Phone

Amount of Donation *

$50

$100.00

$250.00

$500.00

$1000.00

Other amount

Please make my donation recur

Monthly

Quarterly

Annually

Please do not place a dollar sign ($), comma (,) or any other symbol in the donation amount blank above- this will cause the payment amount to be incorrect or to fail.

Donor Privacy

I am willing to have my name affiliated with my donation.

I wish to remain anonymous.

Donation Notes

By submitting this online form, I understand and agree that IOMA will have my contact details for the purpose of processing my information and ensuring full participation.

Payment Information

IOMA has transitioned to our own secure payment gateway. As a result of this change, a 3.25% convenience fee will apply to all credit card payments to help IOMA cover the cost of accepting credit cards. Please let us know if you have any questions. We appreciate your continued support of IOMA.

If you'd like to avoid the credit card processing fee, please mail a check to IOMA at 1415 28th Street, Suite 400, West Des Moines, IA 50266.

Amount

Payment Processing Fee

Total Due

Payment Method

Secure Payment Processing (credit card)

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