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class="icon icon-home2"><use xlink:href="#icon-home2"></use></svg><span><span><a href="https://gi.org/">Gi.org</a> / <span class="breadcrumb_last" aria-current="page">Donation Form</span></span></span></div> </nav> <header class="bg-triangles-primary text-inverse"> <div class="container p-y-md"> <h1 style="display:none" class="main-title"> contentapihead </h1> </div> </header> <main id="main" class=" container p-y-lg main-content"> <article id="post-22865" class="post-22865 page type-page status-publish hentry"> <style> #main p.error{color: red; font-weight:bold;} input[type="text"]{display: inline;} </style> <h2 class="page-title m-b-md">Donation Form - The G.U.T. Fund</h2> <div class="row"> <div class="m-t-sm m-b-md"> <img src="http://gi.org/wp-content/uploads/2023/04/GUT_Fund_donation_form_logos.jpg" height="126" alt="G.U.T. Fund, ACG Institute, and LE&E Center logos"/> </div> </div> <p class="m-t-sm">Thank you for your charitable gift to the American College of Gastroenterology through support of the G.U.T. Fund. Your gift directly supports ACG Institute programs that advance clinical GI research, education and leadership training, health equity, and much more. Please contact ACG at 301-263-9000 with any questions about your gift or for more information.</p> <div class="gform_wrapper gform_legacy_markup_wrapper"> <form id="donationform" method="post" action="https://members.gi.org/donate/index.asp"> <div class="gform_body gform-body"> <ul class="gform_fields top_label form_sublabel_below description_below"> <li class="gfield" > <input type="hidden" name="paytime" value="yep"> <p>Choose Amount to Donate</p> <p> <label class="chooseamount m-r-md"><input type="radio" name="chooseamount" value="250" /> $250</label> <label class="chooseamount m-r-md"><input type="radio" name="chooseamount" value="500" /> $500</label> <label class="chooseamount m-r-md"><input type="radio" name="chooseamount" value="1000" /> $1,000</label> <label class="chooseamount m-r-md"><input type="radio" name="chooseamount" value="2500" /> $2,500</label> <label class="chooseamount m-r-md"><input type="radio" name="chooseamount" value="5000" /> $5,000</label> <label class="chooseamount m-r-md"><input type="radio" name="chooseamount" value="other" /> Other</label> </p> <div id="otherpassvalue" data-num=""></div> <div id="otherwrap" style="display: none;"><p>Enter Amount of Donation to Charge Your Credit Card (Minimum of $10.00 required)<br> $ <input type="text" id="amountother" name="amountother" value=""></p></div> <hr> <p>Amount: $<span id="totalamount"></span> <input type="hidden" id="ioc_order_total_amount" name="ioc_order_total_amount" value=""></p> <p>Type of Gift<br><br> <select name="gifttype" id="gifttype"> <option></option> <option>Unrestricted Gift</option> <option>Pledge Payment</option> <option>Memorial/Tribute Gift</option> </select></p> <div id="memorialwrap" style="display: none;"> <p class="p-l-md">If this is a Memorial/Tribute Gift please enter the information below:<br><br> <label for="inhonorof">Name</label><br> <input type="text" id="inhonorof" name="inhonorof" style="width: 50%" value=""><br><br> <label for="inhonorof">Address</label><br> <input type="text" id="inhonorof_address" name="inhonorof_address" style="width: 50%" value=""></p> </div> <hr> </li> <li class="gfield" > <table cellpadding="0" cellspacing="0" border="0"> <tr><td class="p-l-0" valign="middle">First Name</td><td class="p-l-0 valign="middle" colspan="2">Last Name</td></tr> <tr><td class="p-l-0" valign="middle"><input type="text" name="ecom_billto_postal_name_first" size="20" maxlength="50" value=""></td><td class="p-l-0" valign="middle"><input type="text" name="ecom_billto_postal_name_last" size="20" maxlength="50" value=""></td></tr> <tr><td class="p-l-0" valign="middle" colspan="3">Billing Address 1</td></tr> <tr><td class="p-l-0" valign="middle" colspan="3"><input type="text" name="ecom_billto_postal_street_line1" size="40" maxlength="75" value=""></td></tr> <tr><td class="p-l-0" valign="middle" colspan="3">Billing Address 2 (optional)</td></tr> <tr><td class="p-l-0" valign="middle" colspan="3"><input type="text" name="ecom_billto_postal_street_line2" size="40" maxlength="75" value=""></td></tr> <tr><td class="p-l-0" valign="middle">City</td><td class="p-l-0" valign="middle">State/Province (i.e., MD or VA) </td><td class="p-l-0" valign="middle">Zip/Postal Code</td></tr> <tr><td class="p-l-0" valign="middle"><input type="text" name="ecom_billto_postal_city" size="15" maxlength="50" value=""></td><td class="p-l-0" valign="middle"><input type="text" name="ecom_billto_postal_stateprov" size="10" maxlength="30" value=""></td><td class="p-l-0" valign="middle"><input type="text" name="ecom_billto_postal_postalcode" size="10" maxlength="20" value=""></td></tr> <tr><td class="p-l-0" valign="middle" colspan="3">Country</td></tr> <tr><td class="p-l-0" valign="middle" colspan="3"> <select name="ecom_billto_postal_countrycode"> <option value=" " selected>(please select a country) <option value="US">United States <option value="AF">Afghanistan <option value="AL">Albania <option value="DZ">Algeria <option value="AS">American Samoa <option value="AD">Andorra <option value="AO">Angola <option value="AI">Anguilla <option value="AQ">Antarctica <option value="AG">Antigua and Barbuda <option value="AR">Argentina <option value="AM">Armenia <option value="AW">Aruba <option value="AU">Australia <option value="AT">Austria <option value="AZ">Azerbaijan <option value="BS">Bahamas <option value="BH">Bahrain <option value="BD">Bangladesh <option value="BB">Barbados <option value="BY">Belarus <option value="BE">Belgium <option value="BZ">Belize <option value="BJ">Benin <option value="BM">Bermuda <option value="BT">Bhutan <option value="BO">Bolivia <option value="BA">Bosnia and Herzegowina <option value="BW">Botswana <option value="BV">Bouvet Island <option value="BR">Brazil <option value="IO">British Indian Ocean Territory <option value="BN">Brunei Darussalam <option value="BG">Bulgaria <option value="BF">Burkina Faso <option value="BI">Burundi <option value="KH">Cambodia <option value="CM">Cameroon <option value="CA">Canada <option value="CV">Cape Verde <option value="KY">Cayman Islands <option value="CF">Central African Republic <option value="TD">Chad <option value="CL">Chile <option value="CN">China <option value="CX">Christmas Island <option value="CC">Cocos (Keeling) Islands <option value="CO">Colombia <option value="KM">Comoros <option value="CG">Congo <option value="CD">Congo, the Democratic Republic of the <option value="CK">Cook Islands <option value="CR">Costa Rica <option value="CI">Cote d'Ivoire <option value="HR">Croatia (Hrvatska) <option value="CU">Cuba <option value="CY">Cyprus <option value="CZ">Czech Republic <option value="DK">Denmark <option value="DJ">Djibouti <option value="DM">Dominica <option value="DO">Dominican Republic <option value="TP">East Timor <option value="EC">Ecuador <option value="EG">Egypt <option value="SV">El Salvador <option value="GQ">Equatorial Guinea <option value="ER">Eritrea <option value="EE">Estonia <option value="ET">Ethiopia <option value="FK">Falkland Islands (Malvinas) <option value="FO">Faroe Islands <option value="FJ">Fiji <option value="FI">Finland <option value="FR">France <option value="FX">France, Metropolitan <option value="GF">French Guiana <option value="PF">French Polynesia <option value="TF">French Southern Territories <option value="GA">Gabon <option value="GM">Gambia <option value="GE">Georgia <option value="DE">Germany <option value="GH">Ghana <option value="GI">Gibraltar <option value="GR">Greece <option value="GL">Greenland <option value="GD">Grenada <option value="GP">Guadeloupe <option value="GU">Guam <option value="GT">Guatemala <option value="GN">Guinea <option value="GW">Guinea-Bissau <option value="GY">Guyana <option value="HT">Haiti <option value="HM">Heard and Mc Donald Islands <option value="VA">Holy See (Vatican City State) <option value="HN">Honduras <option value="HK">Hong Kong <option value="HU">Hungary <option value="IS">Iceland <option value="IN">India <option value="ID">Indonesia <option value="IR">Iran (Islamic Republic of) <option value="IQ">Iraq <option value="IE">Ireland <option value="IL">Israel <option value="IT">Italy <option value="JM">Jamaica <option value="JP">Japan <option value="JO">Jordan <option value="KZ">Kazakhstan <option value="KE">Kenya <option value="KI">Kiribati <option value="KP">Korea, Democratic People's Republic of <option value="KR">Korea, Republic of <option value="KW">Kuwait <option value="KG">Kyrgyzstan <option value="LA">Lao People's Democratic Republic <option value="LV">Latvia <option value="LB">Lebanon <option value="LS">Lesotho <option value="LR">Liberia <option value="LY">Libyan Arab Jamahiriya <option value="LI">Liechtenstein <option value="LT">Lithuania <option value="LU">Luxembourg <option value="MO">Macau <option value="MK">Macedonia, The Former Yugoslav Republic of <option value="MG">Madagascar <option value="MW">Malawi <option value="MY">Malaysia <option value="MV">Maldives <option value="ML">Mali <option value="MT">Malta <option value="MH">Marshall Islands <option value="MQ">Martinique <option value="MR">Mauritania <option value="MU">Mauritius <option value="YT">Mayotte <option value="MX">Mexico <option value="FM">Micronesia, Federated States of <option value="MD">Moldova, Republic of <option value="MC">Monaco <option value="MN">Mongolia <option value="MS">Montserrat <option value="MA">Morocco <option value="MZ">Mozambique <option value="MM">Myanmar <option value="NA">Namibia <option value="NR">Nauru <option value="NP">Nepal <option value="NL">Netherlands <option value="AN">Netherlands Antilles <option value="NC">New Caledonia <option value="NZ">New Zealand <option value="NI">Nicaragua <option value="NE">Niger <option value="NG">Nigeria <option value="NU">Niue <option value="NF">Norfolk Island <option value="MP">Northern Mariana Islands <option value="NO">Norway <option value="OM">Oman <option value="PK">Pakistan <option value="PW">Palau <option value="PA">Panama <option value="PG">Papua New Guinea <option value="PY">Paraguay <option value="PE">Peru <option value="PH">Philippines <option value="PN">Pitcairn <option value="PL">Poland <option value="PT">Portugal <option value="PR">Puerto Rico <option value="QA">Qatar <option value="RE">Reunion <option value="RO">Romania <option value="RU">Russian Federation <option value="RW">Rwanda <option value="KN">Saint Kitts and Nevis <option value="LC">Saint LUCIA <option value="VC">Saint Vincent and the Grenadines <option value="WS">Samoa <option value="SM">San Marino <option value="ST">Sao Tome and Principe <option value="SA">Saudi Arabia <option value="SN">Senegal <option value="SC">Seychelles <option value="SL">Sierra Leone <option value="SG">Singapore <option value="SK">Slovakia (Slovak Republic) <option value="SI">Slovenia <option value="SB">Solomon Islands <option value="SO">Somalia <option value="ZA">South Africa <option value="GS">South Georgia and the South Sandwich Islands <option value="ES">Spain <option value="LK">Sri Lanka <option value="SH">St. Helena <option value="PM">St. Pierre and Miquelon <option value="SD">Sudan <option value="SR">Suriname <option value="SJ">Svalbard and Jan Mayen Islands <option value="SZ">Swaziland <option value="SE">Sweden <option value="CH">Switzerland <option value="SY">Syrian Arab Republic <option value="TW">Taiwan <option value="TJ">Tajikistan <option value="TZ">Tanzania, United Republic of <option value="TH">Thailand <option value="TG">Togo <option value="TK">Tokelau <option value="TO">Tonga <option value="TT">Trinidad and Tobago <option value="TN">Tunisia <option value="TR">Turkey <option value="TM">Turkmenistan <option value="TC">Turks and Caicos Islands <option value="TV">Tuvalu <option value="UG">Uganda <option value="UA">Ukraine <option value="AE">United Arab Emirates <option value="GB">United Kingdom <option value="UM">United States Minor Outlying Islands <option value="UY">Uruguay <option value="UZ">Uzbekistan <option value="VU">Vanuatu <option value="VE">Venezuela <option value="VN">Viet Nam <option value="VG">Virgin Islands (British) <option value="VI">Virgin Islands (U.S.) <option value="WF">Wallis and Futuna Islands <option value="EH">Western Sahara <option value="YE">Yemen <option value="YU">Yugoslavia <option value="ZM">Zambia <option value="ZW">Zimbabwe </select> </td></tr> <tr><td class="p-l-0" valign="middle" colspan="3">Email</td></tr> <tr><td class="p-l-0" valign="middle" colspan="3"><input type="text" name="ecom_billto_online_email" size="15" maxlength="75" value=""></td></tr> <tr><td class="p-l-0" valign="middle" colspan="3">Credit Card Type</td></tr> <tr><td class="p-l-0" valign="middle" colspan="3"><select name="ecom_payment_card_type"> <option value="001">Visa</option> <option value="002">MasterCard</option> <option value="003">American Express</option> </select></td></tr> <tr><td class="p-l-0" valign="middle" colspan="3">Credit Card Number (do not include spaces or dashes)<br /> <font color="red"><strong>*We Only Accept Mastercard, Visa and American Express</strong></font></td></tr> <tr><td class="p-l-0" valign="middle" colspan="3"><input type="text" name="ecom_payment_card_number" size="19" maxlength="19" autocomplete="off" value=""></td></tr> <tr> <td colspan="3" valign="middle" class="highlight p-l-0">Card Verification Number from Credit Card</td> </tr> <tr> <td valign="middle" colspan="3" class="p-l-0"> <input type="text" name="ecom_cvn_number" size="10" maxlength="5" value=""> </td> </tr> <tr> <td colspan="3" valign="middle" class="p-l-0">Visa and Mastercard - The verification number is a 3-digit number printed on the back of your card.<br />American Express - The American Express verification number is a 4-digit number printed on the front of your card.</td> </tr> <tr><td class="p-l-0" valign="middle">Exp. Date - Month</td><td class="p-l-0" valign="middle" colspan="2">Exp. Date - Year</td></tr> <tr><td class="p-l-0" valign="middle"><select name="ecom_payment_card_expdate_month" size="1"> <option value="01">January</option> <option value="02">February</option> <option value="03">March</option> <option value="04">April</option> <option value="05">May</option> <option value="06">June</option> <option value="07">July</option> <option value="08">August</option> <option value="09">September</option> <option value="10">October</option> <option value="11">November</option> <option value="12">December</option> </select></td><td class="p-l-0" valign="middle" colspan="2"> <select name="ecom_payment_card_expdate_year" size="1"> <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> <option value="2026">2026</option> <option value="2027">2027</option> <option value="2028">2028</option> <option value="2029">2029</option> <option value="2030">2030</option> </select></td></tr> <tr><td class="p-l-0" colspan="3" valign="middle"><input type="submit" name="Submit" value="Submit"></td></tr> </table> </li> </ul> </div> </form> </div> <script src="https://www.google.com/recaptcha/api.js?render=6Lf9UfUUAAAAALzxRiI-V34FIhWILdBdcken8ytm"></script> <script> jQuery(document).ready(function (event) { var $chooseAmount = jQuery(".chooseamount"), $amountOther = jQuery("#amountother"), $ioc_order_total_amount = jQuery("#ioc_order_total_amount"), $totalAmount = jQuery("#totalamount"), $gifttype = jQuery("#gifttype"), $memorialwrap = jQuery("#memorialwrap"), $otherWrap = jQuery("#otherwrap"); $gifttype.change(function () { var giftVal = $gifttype.val(); if (giftVal === "Memorial/Tribute Gift") { $memorialwrap.show(); } else { $memorialwrap.hide(); } }); $chooseAmount.change(function () { var chooseVal = jQuery("input[type=radio][name=chooseamount]:checked").val(); $totalAmount.text(""); 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