Please print this form and send with your cheque or credit card payment to:
Epilepsy Toronto
510 King Street East
Suite 224
Toronto, ON
M5A 1M1
I would like to make a Memorial Donation to the Epilepsy Toronto in the name of (deceased): __________________________________
Gift amount:
$25
$40
$50
$75
$100
Other: ___________________________________
Method of payment:
Cheque
VISA
Mastercard
Card Number: _____________________________________
Expiry date: ___________
Signature: ________________________________________
* Tax receipts provided for all donations over $10.00
Donor Name: __________________________________________
Address: ______________________________________________
City: _____________ Province: _______ Postal Code: _______
Phone: __________________ Fax: ___________________
E-mail: __________________________________________
please acknowledge this donation to:
Name: __________________________________________________
Address: ________________________________________________
City: ______________ Province: ________ Postal code: _________
Relationship to deceased: __________________________________
|
