DONATION FORM
YES! I would like to make a donation to The Leukemia & Lymphoma Society of Canada to support the efforts of the
following participant:
PARTICIPANT’S NAME:
PARTICIPANT’S EVENT:
DONATION INFORMATION
AMOUNT:
$500
$400
$300
$200
$100
$50
$25
Other (please specify):
DATE OF DONATION:
TYPE OF DONATION:
Personal Donation
MY EMPLOYER WILL MATCH THIS DONATION:
Corporate Donation
Yes (completed company form attached)
No
DONOR INFORMATION (Please type or print clearly to ensure your receipt information will be accurate)
NAME:
EMPLOYER:
MAILING ADDRESS:
CITY:
PROVINCE:
POSTAL CODE:
HM PHONE:
WK PHONE:
CL PHONE:
EMAIL ADDRESS:
WOULD YOU LIKE A TAX RECEIPT (An official Canadian income tax receipt will be issued for donations of $25 or more
where the donor’s complete mailing address has been provided. For donations of less than $25, a receipt will be
issued upon request)?
Yes
No
FOR CORPORATE OR US RESIDENT DONATIONS, A LETTER ACKNOWLEDGING DONATION IS SUFFICIENT?
Yes
No
PAYMENT INFORMATION
I HAVE ENCLOSED A CHEQUE (please make payable to “The Leukemia & Lymphoma Society of Canada” and write
the
name of the walker/runner in the memo field)
PLEASE CHARGE MY CREDIT CARD
Type of Card:
MC
VISA
AMEX
Card Number:
Expiry Date:
Security Code:
Name As It Appears On Card:
Signature:
THANK YOU FOR YOUR KIND & GENEROUS SUPPORT!
Please mail or fax this form and cheques to the office closest to you:
The Leukemia & Lymphoma Society of Canada
Halifax Office:
HS2- 1660 Hollis St
Halifax, N.S.
B3J 1V7
Montreal Office
602-740 rue St.Maurice
Montreal, QC
H3C 1L5
The Leukemia & Lymphoma Society of Canada (www.llscanada.org)
Ontario Region Office
802-2 Lansing Square,
Suite 802
Toronto, ON
M5G 1V2
Calgary Office
#316, 1212-31st Ave. NE,
Calgary, Alberta
T2E 7S8
Vancouver Office:
310-1682 West 7th Avenue
Suite 310
Vancouver, BC
V6J 4S6
Charitable Business No. 10762 3654 RR0001
FOR OFFICE USE ONLY
The Leukemia & Lymphoma Society of Canada (www.llscanada.org)
Charitable Business No. 10762 3654 RR0001
DONATION FORM
PARTICIPANT INFORMATION
PARTICIPANT’S NAME:
PARTICIPANT’S EVENT:
DONATION INFORMATION (Please type or print clearly. Tax receipts will only be issued if ALL information is complete and legible)
POSTAL
RECEIPT
DONOR NAME OR EVENT
MAILING ADDRESS (street #, city, province)
CODE
REQUIRED?
(required)
($25 min)
Y
N
DONATION
AMOUNT
$
Y
N
$
Y
N
$
Y
N
$
Y
N
$
Y
N
$
Y
N
$
Y
N
$
TOTAL DONATIONS
$
Please do not mail cash. Instead, kindly write a cheque or provide your credit card number to cover the cash donation amount. Please make cheques payable to “The Leukemia
& Lymphoma Society of Canada” and write your name in the memo field. An official Canadian income tax receipt will be issued for donations of $25 or more where the donor’s
complete mailing address is provided. For donations of less than $25, a receipt will be issued upon request.
Please mail or fax this form and cheques to the following office closest to you:
The Leukemia & Lymphoma Society of Canada
Halifax Office:
HS2- 1660 Hollis St
Halifax, N.S.
B3J 1V7
Montreal Office
602-740 rue St.Maurice
Montreal, QC
H3C 1L5
Ontario Region Office
802-2 Lansing Square,
Suite 802
Toronto, ON
M5G 1V2
Calgary Office
#316, 1212-31st Ave. NE,
Calgary, Alberta
T2E 7S8
Vancouver Office:
310-1682 West 7th Avenue
Suite 310
Vancouver, BC
V6J 4S6
FOR OFFICE USE ONLY
The Leukemia & Lymphoma Society of Canada (www.llscanada.org)
Charitable Business No. 10762 3654 RR0001