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