Khartum Ladies' Auxiliary

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donate_form.pdf
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DONOR INFORMATION FORM

First  Name   ________________________________
 
Last  Name _________________________________
 
Address  Line 1 ______________________________
 
Address  Line 2 ______________________________
 
City  ______________________________________  Province / State ______________
 
Country  ___________________________________  Postal / Zip Code _____________
 
Phone  Number ________________________   Email address    _______________________________

 
Type of Donation:
 
“General” ___              “In Memory Of”  ___          “In Honor Of” ___

 Name of Person being honored or remembered:  _______________________________
 
“In Memory Of” or “In Honor Of” Certificate to be mailed  to:

First  Name  _________________________________

Last  Name   _________________________________

Address  Line 1 _______________________________

Address  Line 2 _______________________________

City  _____________________________________   Province / State ______________

Country  __________________________________   Postal / Zip Code _____________
 
Payment Method:

By Credit Card:   Yes ___  No ___   Amount _________

Card Type - please circle (eg Mastercard, Visa, American Express):    Card Number______________________
 
Expiration Date:   mm __ yy  __

CSC or CVC Number _____ (this is usually the last 3 numbers located on the back of your card)
 ****************************************************************************

By Cheque:   Yes ___ No ___  Amount _________  (Make payable to Khartum Ladies' Auxiliary)
 
Please mail completed form to:
    Treasurer    
    Khartum Ladies’ Auxiliary
    c/o Khartum Shriners
    1155 Wilkes Avenue
    Winnipeg, MB R3P 1B9

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Photo Section
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Contact Us

Khartum Ladies' Auxiliary
Winnipeg, MB
Email: 
info@khartumladiesauxiliary.com