Please Print and Return with Donation
Name: _________________________________
Company: _________________________________
Address: _________________________________
City: _________________________________
Postal Code: _________________________________
Telephone: _________________________________
Fax: _________________________________
   
I WISH TO MAKE THE FOLLOWING DONATION TO:
ANAPHYLAXIS FOUNDATION OF CANADA
   
$25     $50     $100     $250     Other Amount
   
I prefer to give: $ _________
   
Method of Payment Cash
Cheque
      (payable to the Anaphylaxis Foundation of Canada)
Visa
American Express
   
Credit Card #: _________________________________
Expiry Date: _________________________________
Print Cardholder's Name: _________________________________
Signature: _________________________________
   
Donations over $10 will receive a Charitable Tax Receipt Charitable Reg. No. 1084417-11
 

Please send form to :

Anaphylaxis Foundation of Canada
2054 - 3080 Yonge Street
Toronto, Ontario, Canada M4N 3N1