| Name: |
_________________________________
|
| Company: |
_________________________________
|
| Address: |
_________________________________
|
| City: |
_________________________________
|
| Postal Code:
|
_________________________________
|
| Telephone: |
_________________________________
|
| Fax: |
_________________________________
|
| |
|
| I WISH
TO MAKE THE FOLLOWING DONATION TO: |
| ANAPHYLAXIS
FOUNDATION OF CANADA |
| |
|
|
$25
$50
$100
$250
Other Amount |
| |
|
| I prefer to
give: $ _________ |
| |
|
| Method of
Payment |
Cash |
| |
Cheque
(payable to the Anaphylaxis Foundation
of Canada) |
|
Visa |
|
American Express |
| |
|
| Credit Card
#: |
_________________________________ |
| Expiry Date: |
_________________________________ |
| Print Cardholder's
Name: |
_________________________________ |
| Signature: |
_________________________________ |
| |
|
| Donations
over $10 will receive a Charitable Tax Receipt Charitable Reg. No.
1084417-11 |
| |
|
Please send form to :
Anaphylaxis Foundation
of Canada
2054 - 3080 Yonge Street
Toronto, Ontario, Canada M4N 3N1
|
