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DONATION REMITTANCE FORM

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					                           DONATION REMITTANCE FORM
                                                     GNGH Foundation
                                                     5546 Portage Rd.
                                                 Niagara Falls, ON L2E 6X2




                          Donation amount:              $_______________
    Payment Method:           cheque              visa            mastercard            other

   Credit card # ________-________-________-________                         expiry date:   _____/_____

     Please note that you can use your credit card to make a secure online donation by clicking
                                    the DONATE NOW button.
               Please issue a charitable tax receipt to:


               Name:               ______________________________________________________
Mr.




                                                                                                          Charitable Business Number : 11923 5885
Ms.
               Address:            ______________________________________________________
Mrs.
Miss
               City:               ______________________________________________________
Mr. & Mrs.
Dr.
               Postal Code:        ______________________________________________________


               Email:              ______________________________________________________



               Please direct this gift to the:

               Area of Greatest Need
               or
               ____________________________________________ (specify equipment or department)

				
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posted:10/15/2012
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