Muscular Dystrophy Canada – Ottawa Chapter
Donation Form
To make your donation by fax, please complete the form below and
fax to Muscular Dystrophy Canada – Ottawa Chapter 613-837-6736.
Your financial contribution will help support the services, recreation
programs and research objectives of MDC. We rely on private and
corporate donations to underwrite the many programs conducted to
benefit the MD community.
Name: ________________________________________
Street address: _________________________________________
______________________________________________________
City: _______________________ Province/State: ______________
Postal/Zip Code: ____________ Telephone: (_____)____________
Your donation amount: $_________________
Payment method (circle one): VISA / MasterCard / American Express
Credit card number: ______________________________________
Expiry date: _______________
Signature: ______________________________________
Tax receipt required: Yes ______
No _______