Registro tardio para la Asamblea - Miembros

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Goal {{formatAmount(campaignStats.goalMeter.goalAmount)}}

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Raised

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Donors

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Registrants

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RAISED OF {{formatAmount(campaignStats.goalMeter.goalAmount)}}

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{{campaignStats.goalMeter.donorCount}} Donor{{campaignStats.goalMeter.donorCount > 1 ? 's':''}}

{{campaignStats.goalMeter.registrantCount}} Registrant{{campaignStats.goalMeter.registrantCount > 1 ? 's':''}}

Celebramos 20 Años + / Celebrating 20 Years +

Precio para registro tardío / Late registration fee

Donate Once

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Other Amount

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USD

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Campaign

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Su información / Your information

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¿Cuál es su relación a Alianza Americas? / What is your relationship to Alianza Americas?

Si es parte de una organización miembro, por favor escoja "Miembro / Member" / If you are part of a member organization, please select "Miembro / Member"

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Nombre/ First Name *

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Apellido / Last Name *

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Nombre de su organización / Organization name *

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Correo electrónico / Email *

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Número de télefono / Phone number *

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Dirección 1 / Address Line 1

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Dirección 2 / Address Line 2

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Ciudad / City

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Estado / State

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Código Postal / Zip Code

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País / Country

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Nombre del representate para las elecciones / Name of representative for Elections

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Restricciones o preferencias dietéticas / Restrictions or Dietary Preference

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Tiene alguna necesidad o requisito de accesibilidad (interpretación, movilidad, audición, visión, etc.) que debamos saber? / Do you have any accessibility needs or requirements (interpretation, mobility, hearing, vision, etc.) that we should be aware of?

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¿Su organización estaría interesada en compartir materiales, actividades, recursos, etc. con el resto de los miembros de Alianza Américas? / Would your organization be interested in sharing activities, resources, materials, etc. with the rest of the Alianza Americas' membership?

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Detalles del pago / Payment Details

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Card

ACH

Tarjeta

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or enter your card details below

Cardholder First Name *

Nombre del portador de la tarjeta

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Cardholder Last Name *

Apellido del portador de la tarjeta

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Cardholder Email

Correo electrónico del portador de la tarjeta

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Card *

Número de la tarjeta

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Billing address is the same as mailing address

La dirección de facturación es la misma que la dirección postal

Address Line 1

Dirección 1

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Address Line 2

Dirección 2

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City

Ciudad

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State/Province

Estado o Provincia

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Zip *

Código Postal

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Country

País

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Transferencia de banco a banco

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Amount:

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Secure Payment

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ACH Payment Confirmation

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Total Amount

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Routing Number

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