Wilton DTC Donation

Advanced Redirect

The patron will be redirect to the following pages based on the authorized result.

Important Note:

The redirect pages have to be secure otherwise no redirect will occur.
If your server is offline for any reason the redirect will fail, resulting in error. If the patron experiences a page not found based on your server’s availability it may result to double charges

Use complete URL including https://

Success landing page * :

Declined landing page * :

The following URL parameters are included in the response and may be used on the landing page via custom programming:

Example Success URL:
https://yourpageurl.com/success-page?on=123456&result=success&response=authorized&t=totalamount&refid=referenceid&trk=tracker

on = OrderNumber
result = success
response = authorized
t = totalamount
refid = referenceid
trk = tracker

Example Decline URL:
https://yourpageurl.com/decline-page?on=123456&result=failure&response=dcl&t=totalamount

on = OrderNumber
result = failure
response = dcl
t = totalamount

Donation Amount

$10

$25

$50

$100

$250

Other

Billing and Contact Information

First Name: *

Middle Initial:

Last Name: *

Email: *

Country: *

Address: *

City: *

State: *

Province:

Zip/PostalCode: *

Phone:*

Full Name

Additional Questions (required by law)

Employer [If Self-Employed, please enter the name of your company or if none, please enter your name] *

Occupation *

If you are under 18 please state your age:

Are you a communicator lobbyist, OR the spouse or dependent child of a communicator lobbyist? *

YesNo

Are you a principal of a state contractor or prospective state contractor? *

YesNo

If yes, please indicate which branch or branches of government the contract(s) is with

LegislativeExecutive

Honor/Memorial Gifts

I want to dedicate my donation to someone:

In Honor Of In Memory Of Tribute To

In Memory Of:

Honoree Name:

Send Email acknowledgement to:

Send Postal Mail acknowledgement:

First Name:

Last Name:

Address Line 1:

Address Line 2:

City:

State:

Zip/Postal Code:

Country:

Dedication Message:

Payment Details

Credit Card

Routing Number: *

Account Number: *

Check Number: *

Account Type: *

Check Type: *

Name on Card: *

Credit Card Number: *

Card Verification (CVV): *

Expiration Date: *

CardExpirationYear

Invoice Number:

Purchase Order Number:

Name: *

Reference Number:

Terms & Conditions

I hereby certify that I am NOT a: a) communicator lobbyist b) spouse or dependent child of a communicator lobbyist, c) principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services d) principal of a state contractor or prospective state contractor, or, if e) I am a principal of a state contractor or prospective state contractor, I am not also an elected public official. I hereby certify and state that all of the information disclosed by me and set forth above on this contributor card is true and accurate to the best of my knowledge and belief. I certify that I am either a United States citizen or a foreign national with permanent resident status in the United States. I certify that this contribution is being made from my personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.

I agree with the terms and conditions.

Advanced Redirect

Your donation:

Honor/Memorial Gifts

You will be charged:

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