| donate_form.pdf |
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
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