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	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 Support quality programs and services for the thousands of people in Toronto who are living with epilepsy by making a tax-deductible contribution to Epilepsy Toronto in the honour of: __________________________________ Gift amount: $25     $40      $50      $75        $100 Other: ___________________________________ This gift commemorates: Birthday Retirement Anniversary 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: __________________________________________ please acknowledge this donation to: Name: __________________________________________________ Address: ________________________________________________ City: ______________ Province: ________ Postal code: _________ Comments: _____________________________________________ top of page
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