Donation Form

To be taken out on the:
15th of the MonthEnd of Month

Starting the month of:
June 2017July 2017August 2017September 2017October 2017November 2017December 2017January 2018February 2018March 2018April 2018May 2018

Name

Address

City

ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Territory

CountryCanadaUnited States

Postal Code

Email

Additional Notes

I would like the tax receipt sent to Myself Gift Recipient Other Recipient

In memory of

Yes I consent to my name and address being sent to the person listed below.