Tarjeta o Paypal
Transferencia Bancaria
<form id="ff1" name="ff1" method="post" action="" enctype="multipart/form-data" onsubmit="return checkForm();" class="pppt_form">
Donacion Unica
Monto
<div class='form-group'> <div class='btn-group'> <button class='btn btn-default amount1' type='button'> $10 </button> <button class='btn btn-default amount2' type='button'> $20 </button> <button class='btn btn-default amount3' type='button'> $50 </button> <button class='btn btn-default amount4' type='button'> $100 </button> <button class='btn btn-default amount5' type='button'> Otro Monto </button> </div> </div>
<input class='form-control' placeholder='Monto a donar' name='item_description' id='item_description' type='text' class='form-control' value=' 0 ' onkeyup='checkFieldBack(this);' style='display: no ne;'/> <input class='form-control' placeholder='$' name='amount' id='amount' type='text' class='form-control' value=' ' onkeyup='checkFieldBack(this);noAlpha(this);' onkeypress='noAlpha(this);'>
Datos personales
<input name="fname" id="fname" type="text" class="form-control" value="" onkeyup="checkFieldBack(this);" placeholder="Nombre" >
<input name="lname" id="lname" type="text" class="form-control" value="" onkeyup="checkFieldBack(this);" placeholder="Apellido">
<input name="email" id="email" type="text" class="form-control" value="" onkeyup="checkFieldBack(this);" placeholder="Email">
<input name="address" id="address" type="text" class="form-control" value="" onkeyup="checkFieldBack(this);" placeholder="Dirección">
<input name="city" id="city" type="text" class="form-control" value="" onkeyup="checkFieldBack(this);" placeholder="Ciudad">
<select name="country" id="country" class="form-control" onchange="checkFieldBack(this);"> <option value="">Selecciona</option> <option value="VE" >Venezuela</option> <option value="US" 1>Estados Unidos</option> <option value="CA" >Canada</option> <option value="UK" >Reino Unido</option> <option value="AU" >Australia</option> <option value="AF" >Afghanistan</option> <option value="AL" >Albania</option> <option value="DZ" >Algeria</option> <option value="AS" >American Samoa</option> <option value="AD" >Andorra</option> <option value="AO" >Angola</option> <option value="AI" >Anguilla</option> <option value="AQ" >Antarctica</option> <option value="AG" >Antigua and Barbuda</option> <option value="AR" >Argentina</option> <option value="AM" >Armenia</option> <option value="AW" >Aruba</option> <option value="AT" >Austria</option> <option value="AZ" >Azerbaijan</option> <option value="BS" >Bahamas</option> <option value="BH" >Bahrain</option> <option value="BD" >Bangladesh</option> <option value="BB" >Barbados</option> <option value="BY" >Belarus</option> <option value="BE" >Belgium</option> <option value="BZ" >Belize</option> <option value="BJ" >Benin</option> <option value="BM" >Bermuda</option> <option value="BT" >Bhutan</option> <option value="BO" >Bolivia</option> <option value="BA" >Bosnia and Herzegovina</option> <option value="BW" >Botswana</option> <option value="BR" >Brazil</option> <option value="BN" >Brunei Darussalam</option> <option value="BG" >Bulgaria</option> <option value="BF" >Burkina Faso</option> <option value="BI" >Burundi</option> <option value="KH" >Cambodia</option> <option value="CM" >Cameroon</option> <option value="CV" >Cape Verde</option> <option value="KY" >Cayman Islands</option> <option value="CF" >Central African Republic</option> <option value="TD" >Chad</option> <option value="CL" >Chile</option> <option value="CN" >China</option> <option value="CX" >Christmas Island</option> <option value="CC" >Cocos (Keeling) Islands</option> <option value="CO" >Colombia</option> <option value="KM" >Comoros</option> <option value="CG" >Congo</option> <option value="CD" >Congo, The Democratic Republic of the</option> <option value="CK" >Cook Islands</option> <option value="CR" >Costa Rica</option> <option value="CI" >Cote D`Ivoire</option> <option value="HR" >Croatia</option> <option value="CY" >Cyprus</option> <option value="CZ" >Czech Republic</option> <option value="DK" >Denmark</option> <option value="DJ" >Djibouti</option> <option value="DM" >Dominica</option> <option value="DO" >Dominican Republic</option> <option value="EC" >Ecuador</option> <option value="EG" >Egypt</option> <option value="SV" >El Salvador</option> <option value="GQ" >Equatorial Guinea</option> <option value="ER" >Eritrea</option> <option value="EE" >Estonia</option> <option value="ET" >Ethiopia</option> <option value="FK" >Falkland Islands (Malvinas)</option> <option value="FO" >Faroe Islands</option> <option value="FJ" >Fiji</option> <option value="FI" >Finland</option> <option value="FR" >France</option> <option value="GF" >French Guiana</option> <option value="PF" >French Polynesia</option> <option value="GA" >Gabon</option> <option value="GM" >Gambia</option> <option value="GE" >Georgia</option> <option value="DE" >Germany</option> <option value="GH" >Ghana</option> <option value="GI" >Gibraltar</option> <option value="GR" >Greece</option> <option value="GL" >Greenland</option> <option value="GD" >Grenada</option> <option value="GP" >Guadeloupe</option> <option value="GU" >Guam</option> <option value="GT" >Guatemala</option> <option value="GN" >Guinea</option> <option value="GW" >Guinea-Bissau</option> <option value="GY" >Guyana</option> <option value="HT" >Haiti</option> <option value="HN" >Honduras</option> <option value="HK" >Hong Kong</option> <option value="HU" >Hungary</option> <option value="IS" >Iceland</option> <option value="IN" >India</option> <option value="ID" >Indonesia</option> <option value="IR" >Iran (Islamic Republic Of)</option> <option value="IQ" >Iraq</option> <option value="IE" >Ireland</option> <option value="IL" >Israel</option> <option value="IT" >Italy</option> <option value="JM" >Jamaica</option> <option value="JP" >Japan</option> <option value="JO" >Jordan</option> <option value="KZ" >Kazakhstan</option> <option value="KE" >Kenya</option> <option value="KI" >Kiribati</option> <option value="KP" >Korea North</option> <option value="KR" >Korea South</option> <option value="KW" >Kuwait</option> <option value="KG" >Kyrgyzstan</option> <option value="LA" >Laos</option> <option value="LV" >Latvia</option> <option value="LB" >Lebanon</option> <option value="LS" >Lesotho</option> <option value="LR" >Liberia</option> <option value="LI" >Liechtenstein</option> <option value="LT" >Lithuania</option> <option value="LU" >Luxembourg</option> <option value="MO" >Macau</option> <option value="MK" >Macedonia</option> <option value="MG" >Madagascar</option> <option value="MW" >Malawi</option> <option value="MY" >Malaysia</option> <option value="MV" >Maldives</option> <option value="ML" >Mali</option> <option value="MT" >Malta</option> <option value="MH" >Marshall Islands</option> <option value="MQ" >Martinique</option> <option value="MR" >Mauritania</option> <option value="MU" >Mauritius</option> <option value="MX" >Mexico</option> <option value="FM" >Micronesia</option> <option value="MD" >Moldova</option> <option value="MC" >Monaco</option> <option value="MN" >Mongolia</option> <option value="MS" >Montserrat</option> <option value="MA" >Morocco</option> <option value="MZ" >Mozambique</option> <option value="NA" >Namibia</option> <option value="NP" >Nepal</option> <option value="NL" >Netherlands</option> <option value="AN" >Netherlands Antilles</option> <option value="NC" >New Caledonia</option> <option value="NZ" >New Zealand</option> <option value="NI" >Nicaragua</option> <option value="NE" >Niger</option> <option value="NG" >Nigeria</option> <option value="NO" >Norway</option> <option value="OM" >Oman</option> <option value="PK" >Pakistan</option> <option value="PW" >Palau</option> <option value="PS" >Palestine Autonomous</option> <option value="PA" >Panama</option> <option value="PG" >Papua New Guinea</option> <option value="PY" >Paraguay</option> <option value="PE" >Peru</option> <option value="PH" >Philippines</option> <option value="PL" >Poland</option> <option value="PT" >Portugal</option> <option value="PR" >Puerto Rico</option> <option value="QA" >Qatar</option> <option value="RE" >Reunion</option> <option value="RO" >Romania</option> <option value="RU" >Russian Federation</option> <option value="RW" >Rwanda</option> <option value="VC" >Saint Vincent and the Grenadines</option> <option value="MP" >Saipan</option> <option value="SM" >San Marino</option> <option value="SA" >Saudi Arabia</option> <option value="SN" >Senegal</option> <option value="SC" >Seychelles</option> <option value="SL" >Sierra Leone</option> <option value="SG" >Singapore</option> <option value="SK" >Slovak Republic</option> <option value="SI" >Slovenia</option> <option value="SO" >Somalia</option> <option value="ZA" >South Africa</option> <option value="ES" >Spain</option> <option value="LK" >Sri Lanka</option> <option value="KN" >St. Kitts/Nevis</option> <option value="LC" >St. Lucia</option> <option value="SD" >Sudan</option> <option value="SR" >Suriname</option> <option value="SZ" >Swaziland</option> <option value="SE" >Sweden</option> <option value="CH" >Switzerland</option> <option value="SY" >Syria</option> <option value="TW" >Taiwan</option> <option value="TI" >Tajikistan</option> <option value="TZ" >Tanzania</option> <option value="TH" >Thailand</option> <option value="TG" >Togo</option> <option value="TK" >Tokelau</option> <option value="TO" >Tonga</option> <option value="TT" >Trinidad and Tobago</option> <option value="TN" >Tunisia</option> <option value="TR" >Turkey</option> <option value="TM" >Turkmenistan</option> <option value="TC" >Turks and Caicos Islands</option> <option value="TV" >Tuvalu</option> <option value="UG" >Uganda</option> <option value="UA" >Ukraine</option> <option value="AE" >United Arab Emirates</option> <option value="UY" >Uruguay</option> <option value="UZ" >Uzbekistan</option> <option value="VU" >Vanuatu</option> <option value="VN" >Viet Nam</option> <option value="VG" >Virgin Islands (British)</option> <option value="VI" >Virgin Islands (U.S.)</option> <option value="WF" >Wallis and Futuna Islands</option> <option value="YE" >Yemen</option> <option value="YU" >Yugoslavia</option> <option value="ZM" >Zambia</option> <option value="ZW" >Zimbabwe</option> </select>
<input name="state" id="state" type="text" class="form-control" value="" onkeyup="checkFieldBack(this);" placeholder="Estado">
<input name="zip" id="zip" type="text" class="form-control" value="" onkeyup="checkFieldBack(this);" placeholder="Codigo Postal">
Información de la tarjeta
<div class="form-group"> <label> Tipo: </label> <input name="cctype" type="radio" value="V" class="lft-field"> <img src="/donate_user/images/ico_visa.jpg" align="absmiddle" class="lft-field cardhide V"> <input name="cctype" type="radio" value="M" class="lft-field"> <img src="/donate_user/images/ico_mc.jpg" align="absmiddle" class="lft-field cardhide M"> <input name="cctype" type="radio" value="A" class="lft-field"> <img src="/donate_user/images/ico_amex.jpg" align="absmiddle" class="lft-field cardhide A"> <input name="cctype" type="radio" value="D" class="lft-field"> <img src="/donate_user/images/ico_disc.jpg" align="absmiddle" class="lft-field cardhide D"> <input name="cctype" type="radio" value="PP" class="lft-field isPayPal"> <img src="/donate_user/images/ico_paypal.png" width="37" height="11" align="absmiddle" class="lft-field paypal cardhide PP"> </div>
<input name="ccname" id="ccname" type="text" class="form-control" onkeyup="checkFieldBack(this);" placeholder="Nombre como aparece en la tarjeta">
<input name="ccn" id="ccn" type="text" class="form-control" onkeyup="checkNumHighlight(this.value);checkFieldBack(this);noAlpha(this);" value="" onkeypress="checkNumHighlight(this.value);noAlpha(this);" onblur="checkNumHighlight(this.value);" onchange="checkNumHighlight(this.value);" maxlength="16" placeholder="Numero de la tarjeta">
<select name="exp1" id="exp1" class="form-control" onchange="checkFieldBack(this);" style="width: 48%;"> <option>Mes expiración</option> <option value="01">01</option> <option value="02">02</option> <option value="03">03</option> <option value="04">04</option> <option value="05">05</option> <option value="06">06</option> <option value="07">07</option> <option value="08">08</option> <option value="09">09</option> <option value="10">10</option> <option value="11">11</option> <option value="12">12</option></select> / <select name="exp2" id="exp2" class="form-control" onchange="checkFieldBack(this);" style="width: 48%;"> <option>Año expiración</option> <option value="2016">2016</option><option value="2017">2017</option><option value="2018">2018</option><option value="2019">2019</option><option value="2020">2020</option><option value="2021">2021</option><option value="2022">2022</option><option value="2023">2023</option><option value="2024">2024</option><option value="2025">2025</option></select>
<input name="cvv" id="cvv" type="text" maxlength="5" class="form-control" onkeyup="checkFieldBack(this);noAlpha(this);" placeholder="CVV"> <a href="#modal-hint" role="button" data-toggle="modal"><img class="hint" src="/donate_user/images/ico_question.jpg" align="absmiddle" border="0" /></a>
Transferencia Bancaria
Los datos bancarios para transferir son:
Beneficiario: CITIZENS FOR INTEGRITY, INC
Dirección Beneficiario: 75 Valencia Ave. Suite 703, Coral Gable , Fl 33134. USA
Cuenta: 9138207756
Banco: Citibank N.A.
Dirección del banco: Key Biscayne, 84 Crandon Blvd, Key Biscayne, Fl 33149 USA
ABA: 266086554
SWIFT: CITIUS33
Una vez realizada la transferencia, por favor haga click AQUÍ para notificar su transferencia.
Ud. recibirá otro correo donde se confirma la recepción efectiva de su donación. Por favor guarde ese mensaje para su registro.
En caso de que tenga alguna pregunta sobre su donación o le gustaría recibir más información sobre nuestro trabajo, por favor no dude en consultarnos por [email protected] o visite nuestra página web www.transparenciave.org. También le invitamos a que participe en nuestras redes Facebook y Twitter.
Atentamente,
Equipo Transparencia Venezuela