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