<!-- https://www.givedirect.org/give/givefrm.asp?CID=1721 -->
<table align="center" id="btable" width="810">
<tr>
<td valign="top" align="center" id="btable">
<h1>
MATHCOUNTS Foundation
</h1>
<h2>
Online Donation Form
</h2>
</td>
</tr>
<tr>
<td></td>
</tr>
<tr>
<td>
<form name="donation" method="post" id="donation">
<!--begin the form-->
<input type="hidden" name="IsSubmitted" value="Yes"> <input type="hidden" name="BaseURL" value=""> <span>
<textarea name="f1" id="f1" value="" rows="2" cols="3">
</textarea></span>
<table border="0">
<tr>
<td width="310">
<table>
<tr>
<td width="20">
<img src="#">
</td>
<td valign="middle" width="330">
<div>
Contact Information
</div>
</td>
</tr>
</table>
<div>
<div>
Name <span>*</span><br>
<input name="dnrfirst" value="" type="text" size="15" maxlength="50" tabindex="1"> <input name="dnrlast" value="" type="text" size="15" maxlength="50" tabindex="2"><br>
Company<br>
<input name="company" value="" type="text" size="36" maxlength="100" tabindex="3"><br>
Address 1 <span>*</span><br>
<input name="dadd1" id="dadd1" value="" type="text" size="36" maxlength="155" tabindex="4"><br>
Address 2<br>
<input name="dadd2" id="dadd2" type="text" value="" size="36" maxlength="155" tabindex="5"><br>
City / State / Zip <span>*</span><br>
<input name="dcity" id="dcity" value="" type="text" size="12" maxlength="60" tabindex="6"> <select name="dstate" id="dstate" tabindex="6">
<option id="USA-AL" value="AL">
AL
</option>
<option id="USA-AK" value="AK">
AK
</option>
<option id="USA-AZ" value="AZ">
AZ
</option>
<option id="USA-AR" value="AR">
AR
</option>
<option id="USA-CA" value="CA">
CA
</option>
<option id="USA-CO" value="CO">
CO
</option>
<option id="USA-CT" value="CT">
CT
</option>
<option id="USA-DE" value="DE">
DE
</option>
<option id="USA-DC" value="DC">
DC
</option>
<option id="USA-FL" value="FL">
FL
</option>
<option id="USA-GA" value="GA">
GA
</option>
<option id="USA-GU" value="GU">
GU
</option>
<option id="USA-HI" value="HI">
HI
</option>
<option id="USA-ID" value="ID">
ID
</option>
<option id="USA-IL" value="IL">
IL
</option>
<option id="USA-IN" value="IN">
IN
</option>
<option id="USA-IA" value="IA">
IA
</option>
<option id="USA-KS" value="KS">
KS
</option>
<option id="USA-KY" value="KY">
KY
</option>
<option id="USA-LA" value="LA">
LA
</option>
<option id="USA-ME" value="ME">
ME
</option>
<option id="USA-MD" value="MD">
MD
</option>
<option id="USA-MA" value="MA">
MA
</option>
<option id="USA-MI" value="MI">
MI
</option>
<option id="USA-MN" value="MN">
MN
</option>
<option id="USA-MS" value="MS">
MS
</option>
<option id="USA-MO" value="MO">
MO
</option>
<option id="USA-MT" value="MT">
MT
</option>
<option id="USA-NE" value="NE">
NE
</option>
<option id="USA-NV" value="NV">
NV
</option>
<option id="USA-NH" value="NH">
NH
</option>
<option id="USA-NJ" value="NJ">
NJ
</option>
<option id="USA-NM" value="NM">
NM
</option>
<option id="USA-NY" value="NY">
NY
</option>
<option id="USA-NC" value="NC">
NC
</option>
<option id="USA-ND" value="ND">
ND
</option>
<option id="USA-OH" value="OH">
OH
</option>
<option id="USA-OK" value="OK">
OK
</option>
<option id="USA-OR" value="OR">
OR
</option>
<option id="USA-PA" value="PA">
PA
</option>
<option id="USA-PR" value="PR">
PR
</option>
<option id="USA-RI" value="RI">
RI
</option>
<option id="USA-SC" value="SC">
SC
</option>
<option id="USA-SD" value="SD">
SD
</option>
<option id="USA-TN" value="TN">
TN
</option>
<option id="USA-TX" value="TX">
TX
</option>
<option id="USA-UT" value="UT">
UT
</option>
<option id="USA-VT" value="VT">
VT
</option>
<option id="USA-VA" value="VA">
VA
</option>
<option id="USA-VI" value="VI">
VI
</option>
<option id="USA-WA" value="WA">
WA
</option>
<option id="USA-WV" value="WV">
WV
</option>
<option id="USA-WI" value="WI">
WI
</option>
<option id="USA-WY" value="WY">
WY
</option>
<option>
----
</option>
<option id="CAN-AB" value="AB">
AB
</option>
<option id="CAN-BC" value="BC">
BC
</option>
<option id="CAN-MB" value="MB">
MB
</option>
<option id="CAN-NB" value="NB">
NB
</option>
<option id="CAN-NL" value="NL">
NL
</option>
<option id="CAN-NT" value="NT">
NT
</option>
<option id="CAN-NS" value="NS">
NS
</option>
<option id="CAN-NU" value="NU">
NU
</option>
<option id="CAN-PE" value="PE">
PE
</option>
<option id="CAN-SK" value="SK">
SK
</option>
<option id="CAN-ON" value="ON">
ON
</option>
<option id="CAN-QC" value="QC">
QC
</option>
<option id="CAN-YT" value="YT">
YT
</option>
<option>
----
</option>
<option id="OS-AA" value="AA">
AA
</option>
<option id="OS-AE" value="AE">
AE
</option>
<option id="OS-AP" value="AP">
AP
</option>
</select> <input name="dzip" id="dzip" value="" type="text" size="8" maxlength="10" tabindex="7"><br>
Country<br>
<select name="CC_COUNTRY">
<option value="Albania">
Albania
</option>
<option value="Algeria">
Algeria
</option>
<option value="American Samoa">
American Samoa
</option>
<option value="Andorra">
Andorra
</option>
<option value="Anguilla">
Anguilla
</option>
<option value="Antigua">
Antigua
</option>
<option value="Argentina">
Argentina
</option>
<option value="Aruba">
Aruba
</option>
<option value="Australia">
Australia
</option>
<option value="Austria">
Austria
</option>
<option value="Azores">
Azores
</option>
<option value="Bahamas">
Bahamas
</option>
<option value="Bahrain">
Bahrain
</option>
<option value="Bangladesh">
Bangladesh
</option>
<option value="Barbados">
Barbados
</option>
<option value="Belgium">
Belgium
</option>
<option value="Belize">
Belize
</option>
<option value="Belarus">
Belarus
</option>
<option value="Benin">
Benin
</option>
<option value="Bermuda">
Bermuda
</option>
<option value="Bolivia">
Bolivia
</option>
<option value="Bonaire">
Bonaire
</option>
<option value="Botswana">
Botswana
</option>
<option value="Brazil">
Brazil
</option>
<option value="Brunei">
Brunei
</option>
<option value="Bulgaria">
Bulgaria
</option>
<option value="Burkina Faso">
Burkina Faso
</option>
<option value="Burundi">
Burundi
</option>
<option value="Cambodia">
Cambodia
</option>
<option value="Cameroon">
Cameroon
</option>
<option value="Canada">
Canada
</option>
<option value="Canary Islands">
Canary Islands
</option>
<option value="Cape Verde Islands">
Cape Verde Islands
</option>
<option value="Cayman Islands">
Cayman Islands
</option>
<option value="Channel Islands">
Channel Islands
</option>
<option value="Chile">
Chile
</option>
<option value="China">
China
</option>
<option value="Colombia">
Colombia
</option>
<option value="Congo">
Congo
</option>
<option value="Cook Islands">
Cook Islands
</option>
<option value="Costa Rica">
Costa Rica
</option>
<option value="Croatia">
Croatia
</option>
<option value="Curacao">
Curacao
</option>
<option value="Cyprus">
Cyprus
</option>
<option value="Czech Republic">
Czech Republic
</option>
<option value="Denmark">
Denmark
</option>
<option value="Djibouti">
Djibouti
</option>
<option value="Dominica">
Dominica
</option>
<option value="Dominican Republic">
Dominican Republic
</option>
<option value="Ecuador">
Ecuador
</option>
<option value="Egypt">
Egypt
</option>
<option value="El Salvador">
El Salvador
</option>
<option value="England">
England
</option>
<option value="Equitorial Guinea">
Equitorial Guinea
</option>
<option value="Eritrea">
Eritrea
</option>
<option value="Estonia">
Estonia
</option>
<option value="Ethiopia">
Ethiopia
</option>
<option value="Faeroe Islands">
Faeroe Islands
</option>
<option value="Fiji">
Fiji
</option>
<option value="Finland">
Finland
</option>
<option value="France">
France
</option>
<option value="French Guiana">
French Guiana
</option>
<option value="French Polynesia">
French Polynesia
</option>
<option value="Gabon">
Gabon
</option>
<option value="Gambia">
Gambia
</option>
<option value="Georgia">
Georgia
</option>
<option value="Germany">
Germany
</option>
<option value="Ghana">
Ghana
</option>
<option value="Gibraltar">
Gibraltar
</option>
<option value="Greece">
Greece
</option>
<option value="Greenland">
Greenland
</option>
<option value="Grenada">
Grenada
</option>
<option value="Guadeloupe">
Guadeloupe
</option>
<option value="Guam">
Guam
</option>
<option value="Guatemala">
Guatemala
</option>
<option value="Guinea">
Guinea
</option>
<option value="Guinea-Bissau">
Guinea-Bissau
</option>
<option value="Guyana">
Guyana
</option>
<option value="Haiti">
Haiti
</option>
<option value="Holland">
Holland
</option>
<option value="Honduras">
Honduras
</option>
<option value="Hong Kong">
Hong Kong
</option>
<option value="Hungary">
Hungary
</option>
<option value="Iceland">
Iceland
</option>
<option value="India">
India
</option>
<option value="Indonesia">
Indonesia
</option>
<option value="Ireland">
Ireland
</option>
<option value="Israel">
Israel
</option>
<option value="Italy">
Italy
</option>
<option value="Ivory Coast">
Ivory Coast
</option>
<option value="Jamaica">
Jamaica
</option>
<option value="Japan">
Japan
</option>
<option value="Jordan">
Jordan
</option>
<option value="Kazakhstan">
Kazakhstan
</option>
<option value="Kenya">
Kenya
</option>
<option value="Kiribati">
Kiribati
</option>
<option value="Kosrae">
Kosrae
</option>
<option value="Kuwait">
Kuwait
</option>
<option value="Kyrgyzstan">
Kyrgyzstan
</option>
<option value="Laos">
Laos
</option>
<option value="Latvia">
Latvia
</option>
<option value="Lebanon">
Lebanon
</option>
<option value="Lesotho">
Lesotho
</option>
<option value="Liberia">
Liberia
</option>
<option value="Liechtenstein">
Liechtenstein
</option>
<option value="Lithuania">
Lithuania
</option>
<option value="Luxembourg">
Luxembourg
</option>
<option value="Macau">
Macau
</option>
<option value="Macedonia">
Macedonia
</option>
<option value="Madagascar">
Madagascar
</option>
<option value="Madeira">
Madeira
</option>
<option value="Malawi">
Malawi
</option>
<option value="Malaysia">
Malaysia
</option>
<option value="Maldives">
Maldives
</option>
<option value="Mali">
Mali
</option>
<option value="Malta">
Malta
</option>
<option value="Marshall Islands">
Marshall Islands
</option>
<option value="Martinique">
Martinique
</option>
<option value="Mauritania">
Mauritania
</option>
<option value="Mauritius">
Mauritius
</option>
<option value="Mexico">
Mexico
</option>
<option value="Moldova">
Moldova
</option>
<option value="Monaco">
Monaco
</option>
<option value="Montserrat">
Montserrat
</option>
<option value="Morocco">
Morocco
</option>
<option value="Mozambique">
Mozambique
</option>
<option value="Myanmar">
Myanmar
</option>
<option value="Namibia">
Namibia
</option>
<option value="Nepal">
Nepal
</option>
<option value="Netherlands">
Netherlands
</option>
<option value="New Caledonia">
New Caledonia
</option>
<option value="New Zealand">
New Zealand
</option>
<option value="Nicaragua">
Nicaragua
</option>
<option value="Niger">
Niger
</option>
<option value="Nigeria">
Nigeria
</option>
<option value="Norfolk Island">
Norfolk Island
</option>
<option value="Northern Ireland">
Northern Ireland
</option>
<option value="Norway">
Norway
</option>
<option value="Oman">
Oman
</option>
<option value="Pakistan">
Pakistan
</option>
<option value="Palau">
Palau
</option>
<option value="Panama">
Panama
</option>
<option value="Papua New Guinea">
Papua New Guinea
</option>
<option value="Paraguay">
Paraguay
</option>
<option value="Peru">
Peru
</option>
<option value="Philippines">
Philippines
</option>
<option value="Poland">
Poland
</option>
<option value="Ponape">
Ponape
</option>
<option value="Portugal">
Portugal
</option>
<option value="Puerto Rico">
Puerto Rico
</option>
<option value="Qatar">
Qatar
</option>
<option value="Reunion">
Reunion
</option>
<option value="Romania">
Romania
</option>
<option value="Rota">
Rota
</option>
<option value="Russia">
Russia
</option>
<option value="Rwanda">
Rwanda
</option>
<option value="Saba">
Saba
</option>
<option value="Saipan">
Saipan
</option>
<option value="Saudi Arabia">
Saudi Arabia
</option>
<option value="Scotland">
Scotland
</option>
<option value="Senegal">
Senegal
</option>
<option value="Seychelles">
Seychelles
</option>
<option value="Sierra Leone">
Sierra Leone
</option>
<option value="Singapore">
Singapore
</option>
<option value="Slovakia">
Slovakia
</option>
<option value="Slovenia">
Slovenia
</option>
<option value="Solomon Islands">
Solomon Islands
</option>
<option value="South Africa">
South Africa
</option>
<option value="South Korea">
South Korea
</option>
<option value="Spain">
Spain
</option>
<option value="Sri Lanka">
Sri Lanka
</option>
<option value="St. Barthelemy">
St. Barthelemy
</option>
<option value="St. Christopher">
St. Christopher
</option>
<option value="St. Croix">
St. Croix
</option>
<option value="St. Eustatius">
St. Eustatius
</option>
<option value="St. John">
St. John
</option>
<option value="St. Lucia">
St. Lucia
</option>
<option value="St. Maarten">
St. Maarten
</option>
<option value="St. Martin">
St. Martin
</option>
<option value="St. Thomas">
St. Thomas
</option>
<option value="Sudan">
Sudan
</option>
<option value="Suriname">
Suriname
</option>
<option value="Swaziland">
Swaziland
</option>
<option value="Sweden">
Sweden
</option>
<option value="Switzerland">
Switzerland
</option>
<option value="Syria">
Syria
</option>
<option value="Tahiti">
Tahiti
</option>
<option value="Taiwan">
Taiwan
</option>
<option value="Tajikistan">
Tajikistan
</option>
<option value="Tanzania">
Tanzania
</option>
<option value="Thailand">
Thailand
</option>
<option value="Tinian">
Tinian
</option>
<option value="Togo">
Togo
</option>
<option value="Tonga">
Tonga
</option>
<option value="Tortola">
Tortola
</option>
<option value="Trinidad and Tobago">
Trinidad and Tobago
</option>
<option value="Truk">
Truk
</option>
<option value="Tunisia">
Tunisia
</option>
<option value="Turkey">
Turkey
</option>
<option value="Tuvalu">
Tuvalu
</option>
<option value="Uganda">
Uganda
</option>
<option value="Ukraine">
Ukraine
</option>
<option value="Union Island">
Union Island
</option>
<option value="United Arab Emirates">
United Arab Emirates
</option>
<option value="United Kingdom">
United Kingdom
</option>
<option value="United States" selected>
United States
</option>
<option value="Uruguay">
Uruguay
</option>
<option value="US Virgin Islands">
US Virgin Islands
</option>
<option value="Uzbekistan">
Uzbekistan
</option>
<option value="Vanuatu">
Vanuatu
</option>
<option value="Venezuela">
Venezuela
</option>
<option value="Vietnam">
Vietnam
</option>
<option value="Virgin Gorda">
Virgin Gorda
</option>
<option value="Wake Island">
Wake Island
</option>
<option value="Wales">
Wales
</option>
<option value="Western Samoa">
Western Samoa
</option>
<option value="Yap">
Yap
</option>
<option value="Yemen">
Yemen
</option>
<option value="Zaire">
Zaire
</option>
<option value="Zambia">
Zambia
</option>
<option value="Zimbabwe">
Zimbabwe
</option>
</select><br>
Telephone<br>
<input name="dphone" value="" type="text" size="36" maxlength="20" tabindex="8"><br>
Email <span>*</span><br>
<input name="demail" value="" type="text" size="36" maxlength="155" tabindex="9"><br>
<br>
</div>
</div>
</td>
<td>
<div>
<table border="0">
<tr>
<td>
<img src="#" alt="Number 2">
</td>
<td valign="middle" width="350">
<div>
Donation Information
</div>
</td>
</tr>
</table>
<div>
<b>Gift amount in USD <span>($10 minimum)</span><br>
$<input name="amt" id="amt" type="text" value="" size="5" maxlength="25" tabindex="10">.00</b>
<p>
<input type="checkbox" name="tributeSelect" tabindex="11" value="on"> My donation is In Honor or In Memory of someone special
</p>
<p>
<!--<b>Donation Preference</b><br>-->
<input name="DonationType" type="radio" value="OneTime" checked tabindex="12">This is a one time donation<br>
<input name="DonationType" type="radio" value="Recurs" tabindex="13">I would like to make this a recurring donation deducted <select name="ccrecurring" tabindex="14">
<option value="Monthly">
Monthly
</option>
<option value="Quarterly">
Quarterly
</option>
<option value="Annually">
Annually
</option>
</select>
</p>
<p>
<b>Comments</b><br>
<span>( You may enter up to 500 characters. ) <input value="500" name="remLen" size="3" maxlength="3"> characters left</span><br>
<textarea name="Comments" rows="3" cols="45" wrap="physical" onkeydown="textCounter(this.form.Comments,this.form.remLen,500);" onkeyup="textCounter(this.form.Comments,this.form.remLen,500);" tabindex="17">
</textarea>
</p>
</div>
</div>
</td>
</tr>
<tr>
<td colspan="2">
<div id="div_tribute" style='display: none;'><br>
<table border="0">
<tr>
<td width="20">
<img src="#">
</td>
<td valign="middle" width="330">
<div>
Tribute Information:
</div>
</td>
</tr>
</table>
<div>
<table>
<tr>
<td>
<table>
<tr>
<td></td>
<td>
<input type="radio" name="tribute" value="IHO" tabindex="18">In Honor Of <input type="radio" name="tribute" value="IMO" tabindex="19">In Memory Of
</td>
</tr>
<tr>
<td>
Name:
</td>
<td>
<input type="text" name="Tribute_Name" maxlength="100" size="35" value="" tabindex="20">
</td>
</tr>
<tr>
<td>
Occasion:
</td>
<td>
<input type="text" name="Tribute_occasion" maxlength="100" size="35" value="" tabindex="21">
</td>
</tr>
<tr>
<td colspan="2" align="left">
<input type="checkbox" name="Tribute_Disclosure" value="on" tabindex="22">I wish to remain anonymous<br>
<input type="checkbox" name="Tribute_Notification" value="on" tabindex="23">Please send a notification of my gift to the following address:
</td>
</tr>
</table>
</td>
<td>
<div id="div_notify" style='display: none;'>
<div>
<table>
<tr>
<td colspan="2" align="right">
<input type="radio" name="Tribute_IncludeAmount" tabindex="24" value="1">Include the amount <input type="radio" name="Tribute_IncludeAmount" checked tabindex="25" value="0">Do not include the amount
</td>
</tr>
<tr>
<td>
Name:
</td>
<td>
<input type="text" name="Tribute_NotifyName" maxlength="100" size="40" value="" tabindex="26">
</td>
</tr>
<tr>
<td>
Email:
</td>
<td>
<input type="text" name="Tribute_Email" maxlength="50" size="40" value="" tabindex="27">
</td>
</tr>
<tr>
<td>
Street:
</td>
<td>
<input type="text" name="Tribute_NotifyAddr" maxlength="200" size="40" value="" tabindex="28">
</td>
</tr>
<tr>
<td>
City / St. / Zip:
</td>
<td>
<input type="text" name="Tribute_NotifyCity" maxlength="60" size="15" value="" tabindex="29"> <input type="text" name="Tribute_NotifyState" maxlength="10" size="2" value="" tabindex="30"> <input type="text" name="Tribute_NotifyZip" maxlength="10" size="10" value="" tabindex="31">
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
</div><!-- End Hide Notify Div -->
<!-- End TributeBox Div --><!-- End Hide Tribute Div -->
</td>
</tr>
<tr>
<td colspan="2">
<!-- ///PAYMENT BOX -->
<br>
<table border="0">
<tr>
<td width="20">
<div id="div_payment">
<img src='images/icons/red4.png'>
</div>
<div id="div_paymentmain">
<img src='images/icons/red3.png'>
</div>
</td>
<td valign="middle" width="330">
<div>
Payment Information:
</div>
</td>
</tr>
</table>
<div>
<table>
<tr>
<td width="10"></td>
<td>
<p>
<b>Credit Card Information</b><br>
<img src="#"><br>
<br>
Credit Card Type <span>*</span><br>
<select name="cctype" tabindex="32">
<option value="Visa">
Visa
</option>
<option value="MasterCard">
MasterCard
</option>
<option value="AmericanExpress">
American Express
</option>
</select><br>
Credit Card Number <span>*</span><br>
<input name="ccard" type="text" value="" size="25" maxlength="25" tabindex="32"><br>
CSC Number <span>* <a href="#">What Is This?</a></span><br>
<input tabindex="33" name="csc" type="text" value="" size="25" maxlength="4"><br>
Expiration Date <span>*</span><br>
Month <select name="ExpMon" tabindex="34">
<option value="1">
1
</option>
<option value="2">
2
</option>
<option value="3">
3
</option>
<option value="4">
4
</option>
<option value="5">
5
</option>
<option value="6">
6
</option>
<option value="7">
7
</option>
<option value="8">
8
</option>
<option value="9">
9
</option>
<option value="10">
10
</option>
<option value="11">
11
</option>
<option value="12">
12
</option>
</select> Year <select name="ExpYear" size="1" tabindex="35">
<option value="11">
2011
</option>
<option value="12">
2012
</option>
<option value="13">
2013
</option>
<option value="14">
2014
</option>
<option value="15">
2015
</option>
<option value="16">
2016
</option>
<option value="17">
2017
</option>
<option value="18">
2018
</option>
<option value="19">
2019
</option>
</select><br>
</p>
</td>
<td width="150"></td>
<td>
<p>
<b>Billing Address</b> - <input type="checkbox" name="SameAddress" value="checkbox" tabindex="36">Same As Contact Address<br>
<br>
Address 1 <span>*</span><br>
<input name="CC_Addr" id="CC_Addr" value="" type="text" size="36" maxlength="155" tabindex="37"><br>
Address 2<br>
<input name="CC_Addr2" id="CC_Addr2" type="text" value="" size="36" maxlength="155" tabindex="38"><br>
City / State / Zip <span>*</span><br>
<input name="CC_City" id="CC_City" value="" type="text" size="12" maxlength="60" tabindex="39"> <input name="CC_State" id="CC_State" value="" type="text" size="2" maxlength="10" tabindex="40"> <input name="CC_Zip" id="CC_Zip" value="" type="text" size="10" maxlength="10" tabindex="41">
</p>
<p>
<b>Thank you for your support!</b>
</p>
<p>
<input type="image" src="#" name="Action" value="Submit" tabindex="42">
</p>
</td>
</tr>
</table>
</div><!-- End Payment Box div -->
</td>
</tr>
</table>
</form>
</td>
</tr>
</table>
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