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General Donation Form - Terry Fox Foundation

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									                               The Terry Fox Foundation
                                               Donation Form
Name:
                                                       All donations of $20 or more will automatically be sent a tax
Address:                                                      receipt. Gifts under $20 can request a receipt.

City/Town:                                                   THANK YOU FOR YOUR SUPPORT!
Province:                                               Please mail this form to your provincial office or fax to
                                                                         the number provided.
Postal Code:
                                                       British Columbia / Yukon Territory
Phone: (       )                                       2669 Shaughnessy Street
                                                       Port Coquitlam, British Columbia V3C 3G7
Email:                                                 Tel: 604 464-2666 Fax: 604 464-2664

                                                       Alberta / Northwest Territories / Nunavut
DONATION: $                                            Suite D 10 - 6115, 3rd St SE
                                                       Calgary, Alberta T2H 2L2
                                                       Tel: 403 212-1336 Fax: 403 212-1343
    Please make my gift in memory of:
                                                       Saskatchewan
                                                       2001 Cornwall Street, Suite 116
                                                       Regina, Saskatchewan S4P 3X9
    Please make my gift in tribute to:                 Tel: 306 757-1662 Fax: 306 757-7422

                                                       Manitoba
Personal Message:                                      543 St Mary's Rd
                                                       Winnipeg, Manitoba R2M 3L4
                                                       Tel: 204 231-5282 Fax: 204 231-5365

                                                       Ontario
                                                       Suite 804, 789 Don Mills Rd
                                                       Toronto, Ontario M3C 1T5
    Please notify the family of this gift:             Tel: 416 924-8252 Fax: 416 924-6597

Name:                                                  Quebec
                                                       Suite 518, 1117 St. Catherine St. West
Address:                                               Montreal, Quebec H3B 1H9
                                                       Tel: 514 499-9747 Fax: 514 499-9924
City/Town:
                                                       New Brunswick / Prince Edward Island
                                                       517 Northumberland St.
Province:                                              Fredericton, NB E3B 3K7
                                                       Tel: 506 458-2618 Fax: 506 459-4572
Postal Code:
                                                       Nova Scotia
                                                       Suite 435, 1657 Barrington St
    I have enclosed a cheque payable to The Terry      Halifax, Nova Scotia B3J 2A1
    Fox Foundation                                     Tel: 902 423-8131 Fax: 902 492-3639

    Please charge this donation to a credit card       Newfoundland and Labrador
                                                       835 Topsail Rd., Suite 202,
                                                       Mt. Pearl, Newfoundland and Labrador A1N 3J6
    VISA               MasterCard            AMEX      Tel: 709 576-8428 Fax: 709 747-7277

Card #:

Expiry (mm/yy):            /         CVV:              Please call toll free 1-888-836-9786 with
                                                       any questions or if you would like to learn
Name on Card:
                                                       more about the Foundation or The Terry Fox
Signature:                                             Run.

								
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