Request Canvas

Artwork Title

This field is hidden when viewing the form

Artwork Year

Canvas Size(Required)

I would like to cover the processing fee.

Yes, I would like to cover the fees so that 100% of my contribution goes to Embracing Our Differences.

No, thank you.

Processing Fee

Price: $0.00

Total

Billing Information

Email(Required)

Phone(Required)

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Shipping Information

Address

Same as Billing Address

Street Address City State / Province / Region ZIP / Postal Code

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Embracing Our Differences, Inc. is a 501(c)(3) not-for-profit corporation. Pursuant to the Revenue Reconciliation Act of 1993, no goods or services were provided in exchange for this gift. EMBRACING OUR DIFFERENCES, INC. MEETS ALL REQUIREMENTS SPECIFIED BY THE FLORIDA SOLICITATION OF CONTRIBUTIONS ACT. A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE 1-800-HELP-FLA (435-7352) WITHIN THE STATE OR AT WWW.FLORIDACONSUMERHELP.COM. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL OR ECOMMENDATION BY THE STATE. REGISTRATION NO. CH19398.