Donation Form

Donor Information (please print)









Postal Code


Telephone (home)


Telephone (business)




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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