FANCONI CANADA Donation Form Print and complete this form and mail or fax (if paying by credit card) to: Fanconi Canada P.O. Box 38157 Castlewood Postal Outlet Toronto, ON M5N 3A9 Tel. and fax: (416) 489-6393
	Name _______________________________________________ Company (if applicable)_____________________________________ Address _____________________________________________ City/Town_____________________________ Prov/State ______ Postal Code__________________Country __________________ Phone (_______)_______________________________________
Type of Donation				Amount
Regular Donation				$
Tribute Donation  Please send a card to the following : Name ____________________________________________ Address ____________________________________________ City ____________________________________________ Prov/State__________  Postal Code__________________ Country _________________			(Circle one) In Honour /Memory of ____________________________ Occasion Birthday Anniversary Birth Other (please specify): ____________________________	$
□ Please put me on your mailing list for Fanconi Canada Newsletters
Total Donation Amount Please make cheques payable to Fanconi Canada Tax receipts will be issued for amounts greater than $5				$
If paying by Credit Card Credit Card Type □ VISA □ MasterCard Credit Card no ___ ___ ___ ___-___ ___ ___ ___-___ ___ ___ ___-___ ___ ___ ___ Expiry Date _____/_____ (mm/yy) Name on Card Signature

Thank you so much for your support of research to cure Fanconi anemia.

admin@fanconicanada.org

www.fanconicanada.org

Charitable Registration No. 868951724 RR 0001