Payment Form
Please ensure you have read the Rules and Rewards section on http://www.liver.ca/liverightawards/awards/rules.aspx
before filling out this payment form.
Name of Company (manufacturer of product):
Name(s) of product(s) entered:
Total number of products entered:
Total number of additional awards categories entered for all products:
product(s) in multiple categories)
(only applies if entering
Entry fee is $100 for each product submitted to each awards category. To determine the total entry fee
required, please calculate as follows:
Total number of products times $100 per product = $
categories entered times $100 per category = $
Total payment amount of $
plus total number of additional awards
for a total entry fee of $
is enclosed.
I am paying by credit card
Credit Card type
Visa
Amex
MasterCard
Card Number
Cardholder’s name
Expiry Date
You may submit your credit card payment by email to bpotkonjak@liver.ca, by fax to 416-491-4952 or by
mail and courier to Canadian Liver Foundation, LIVERight Awards, Suite 1500, 2235 Sheppard Avenue East,
Toronto, ON, M2J 5B5.
I am paying by cheque or money order
Cheques and money orders should be made payable to Canadian Liver Foundation. Please indicate
“LIVERight Awards” in the description portion of your cheque or money order.
You may submit your cheque or money order payment by mail or courier to:
Canadian Liver Foundation, LIVERight Awards,
Suite 1500, 2235 Sheppard Avenue East, Toronto, ON, M2J 5B5.
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