Name: {Name (First):2.3} {Name (Last):2.6}

Address: {Address (Street Address):3.1} {Address (Address Line 2):3.2}

City: {Address (City):3.3}

State/Province: {State:22}{Province/Territory:24}{Province/Region:25}

Postal Code: {Zip Code:23}{Postal Code:26}

Country: {Country:106}

Phone: {Phone:53}

Email: {Email:5}

Heard About STC: {Where Did You Hear About STC?:14}

Membership Level: {Donation amount*: (All donations are charged in U.S. dollars) US D:59} {Donation amount*: (All donations are charged in U.S. dollars) Int D:65}

Premium Requested: {Free Gift::95} {Select Free Gift::96}{Select Free Gift::97}{Free Gift::98}{Free Gift::99}{Free Gift::100}

Donation to be Charged: {Total:93}

Name: {Name (First):2.3} {Name (Last):2.6}

Address: {Address (Street Address):3.1} {Address (Address Line 2):3.2}

City: {Address (City):3.3}

State/Province: {State:22}{Province/Territory:24}{Province/Region:25}

Postal Code: {Zip Code:23}{Postal Code:26}

Country: {Country:106}

Phone: {Phone:53}

Email: {Email:5}

Heard About STC: {Where Did You Hear About STC?:14}

Name: {Gift Recipient Name (First):10.3} {Gift Recipient Name (Last):10.6}

Address: {Gift Recipient Address (Street Address):11.1} {Gift Recipient Address (Address Line 2):11.2}

City: {Gift Recipient Address (City):11.3}

State/Province: {Gift Recipient State:27}{Gift Recipient Province/Territory:29}{Gift Recipient Province/Region:30}

Postal Code: {Gift Recipient Zip Code:28}{Gift Recipient Postal Code:31}

Country: {Country:107}

Email: {Gift Recipient Email:12}

Gift From: {This Gift is From:103}

Gift Message: {Gift Occasion Message:13}

Send Gift To: {Please send the Gift to:15}

Donation: {Donation amount*: (All donations are charged in U.S. dollars) US G:71} {Donation amount*: (All donations are charged in U.S. dollars) Int G:72}

Premium Requested: {I\'d like a thank you gift for an additional $3 (select one)::95} {Select Free Gift::96}{Select Free Gift::97}{Free Gift::98}{Free Gift::99}{Free Gift::100}

Total Donation: {Total:105}

Shipping: {Mailing Method G US:73}{Mailing Method GG US:74}{Mailing Method G Int:75}{Mailing Method GG int:76}

Amount to be Charged: {Total:93}