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$180     $100     $72     $54     $36

Other   ($10 minimum)

 I understand that my pledge amount will be automatically withdrawn from my credit card on the first day of each month. Credit authorization may be canceled anytime with written notice.

Please make my donation in honour of   memory of

Name:

Address:

City:   Prov.    PC:

Phone:    Email:

VISA           Master Card

Card number:   exp.(mm/yyyy) /

Credit Card CVV Number: 

Thank you for your support.
An official receipt for income tax purposes
will be mailed to you at the end of December for all donations of the past year.

If you have any questions, please don't hesitate to contact us: [email protected]