Donation Form

Donor Information (please print)

Name

 

Address

 

City

 

Province

 

Postal Code

 

Telephone (home)

 

Telephone (business)

 

E-mail

 

I (we) would like to make a donation of:{ $35{ $50{ $100{ other$____________

 

Donation made on behalf of or in memory of ______________________________________________

I (we) plan to make this contribution in the form of: cash cheque credit card other

Credit card type

 

Credit card number

 

Expiration date

 

Authorized signature

 

 

Please note: This is not a tax receipt. Donations of $20 or more will receive a charitable receipt by mail upon request.

Send completed forms to:

Autism Ontario - Sarnia Lambton Chapter
PO Box 2564
105 Christina St,
Sarnia, ON N7T 7V8

 














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