DRCNet Donation Form
Sale! T-shirts $17, Mugs and Mousepads $12 (doesn't include membership)

Based on member feedback, we have decided to open up
merchandise purchases to non-members: t-shirts are now $17 and mugs and
mousepads $12. Additional donations or membership contributions are very much
needed but are not mandatory. Please add $5 for shipping outside North America.
This form transmits your information through a secure SSL connection to drcnet.org.

First Name
Last Name
Address 1
Address 2
City
State	select from this listALABAMAALASKAAMERICAN SAMOAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAF.S. MICRONESIAFLORIDAGEORGIAGUAMHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARSHALL ISLANDSMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTANORTH MARIANA ISLANDSOHIOOKLAHOMAOREGONPALAUPENNSYLVANIAPUERTO RICORHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGIN ISLANDSVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMINGARMED FORCES AMERICASARMED FORCES (OTHER)
Country	select from this listUNITED STATESNorth America (other):ANTIGUA AND BARBUDABAHAMASBARBADOSBELIZECANADACOSTA RICACUBADOMINICADOMICAN REPUBLICEL SALVADORGRENADAGUATEMALAHAITIHONDURASJAMAICAMEXICONICARAGUAPANAMASAINT KITTS AND NEVISSAINT LUCIAST. VINCENT/GRENADINESTRINIDAD AND TOBAGOSouth America (select country):ARGENTINABOLIVIABRAZILCHILECOLOMBIAECUADORGUYANAPARAGUAYPERUSURINAMEURUGUAYVENEZUELAEurope (select country):ALBANIAANDORRAAUSTRIABELARUSBELGIUMBOSNIA/HERZEGOVINABULGARIACROATIACZECH REPUBLICDENMARKESTONIAFINLANDFRANCEGERMANYGREECEHUNGARYICELANDIRELANDITALYLATVIALIECHTENSTEINLITHUANIALUXEMBOURGMACEDONIAMALTAMOLDOVAMONACONETHERLANDSNORWAYPOLANDPORTUGALROMANIARUSSIAN FEDERATIONSAN MARINOSLOVAK REPUBLICSLOVENIASPAINSWEDENSWITZERLANDUKRAINEUNITED KINGDOMYUGOSLAVIAAustralia (select province):AUSTR. CAPITAL TERRITORYNEW SOUTH WALESNORFOLK ISLANDNORTHERN TERRITORYQUEENSLANDSOUTH AUSTRALIATASMANIAVICTORIAWESTERN AUSTRALIAOceania (other):FIJIMARSHALL ISLANDSMICRONESIANEW ZEALANDPALAUPAPUA NEW GUINEASAMOASOLOMON ISLANDSVANUATAAsia, including Middle East:AFGHANISTANARMENIAAZERBAIJANBAHRAINBANGLADESHBHUTANBRUNEI DARUSSALAMCAMBODIACHINACYPRUSGEORGIAINDIAINDONESIAIRANIRAQISRAELJAPANJORDANKAZAKSTANKOREA (NORTH)KOREA (SOUTH)KUWAITKYRGYZSTANLAOSLEBANONMALAYSIAMALDIVESMONGOLIAMYANMARNEPALOMANPAKISTANPHILIPPINESQATARSAUDI ARABIASINGAPORESRI LANKASYRIATAJIKISTANTHAILANDTURKEYTURKMENISTANUNITED ARAB EMIRATESUZBEKISTANVIETNAMYEMENAfrica (select country):ALGERIAANGOLABENINBOTSWANABURKINA FASOBURUNDICAMEROONCAPE VERDECENTRAL AFRICAN REPUBLICCHADCOMOROSCONGOCOTE D'IVOIREDEM. REP. OF CONGODJIBOUTIEGYPTEQUATORIAL GUINEAERITREAETHIOPIAGABONGAMBIAGHANABUINEAGUINEA-BISSAUKENYALESOTHOLIBERIALIBYAMADAGASCARMALAWIMALIMAUTIRANIAMAURITIUSMOROCCOMOZAMBIQUENAMIBIANIGERNIGERIARWANDASAO TOME AND PRINCIPESENEGALSEYCHELLESSIERRA LEONESOMALIASOUTH AFRICASUDANSWAZILANDTANZANIATOGOTUNISIAUGANDAZAMBIAZIMBABWE
Zip Code
Phone
E-mail Address
T-Shirt Purchases ($17 each, provide number, color and size)
Mug Purchases ($12 each)
Mousepad Purchases ($12 each)
Donation Amount (for membership with gift option)	$35 donation (qualifies for any one gift) $30 donation (qualifies for mug or mousepad) $60 donation (qualifies for any two gifts) $90 (qualifies for any three gifts)$25 for standard membership, no gift$100 donation (friend)$250 donation (sustainer)$500 donation (patron)$1,000 donation (benefactor)
Optional Additional Donation
Optional Monthly Donation
Tax-deductibility	Non-tax-deductible donation to the Drug Reform Coordination NetworkTax-deductible donation to the DRCNet Foundation
Payment Method	select payment methodcheck or money ordercredit card - Visacredit card - Mastercardcredit card - Discovercredit card - AMEXPayPal
Credit Card Number
Expiration Date
Choose Your Free Educational Gift(s)	select your gift Send me a DRCNet StopTheDrugWar.org t-shirt ($35 or over). Send me a DRCNet StopTheDrugWar.org mug ($30 or over). Send me a DRCNet StopTheDrugWar.org mousepad ($30 or over).Send me a t-shirt and a mug ($60 or over).Send me a t-shirt and a mousepad ($60 or over).Send me a mug and a mousepad ($90 or over).Send me all three.Don't send me any gift, keep all my money for DRCNet's work.
T-shirt Size and Color	select your t-shirt size if ordering one Send me a small, black t-shirt.Send me a small, blue t-shirt.Send me a medium, black t-shirt.Send me a medium, blue t-shirt.Send me a large, black t-shirt.Send me a large, blue t-shirt.Send me an extra large, black t-shirt.Send me an extra large, blue t-shirt.Send me an XXL, black t-shirt.Send me an XXL, blue t-shirt.
Any Other Notes or Instructions
Privacy	May we share your mailing address with selected allied organizations?You may share my address with selected allied organizations (mailing address, no e-mail share).Do not share my address.