Personal Donations
	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 At Epilepsy Toronto we believe that everyone with epilepsy should have the opportunity to live with dignity. All it takes is $25, $40, $50, $75 $100 or whatever you can afford to help make this vision a complete and lasting reality. I would like to make a contribution* to Epilepsy Toronto in the amount of: $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 Name: __________________________________________ Address: _________________________________________ City: _____________  Province: _______    Postal Code: _______ Phone: __________________     Fax: ___________________ E-mail: __________________________________________ top of page
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