Parkinson Society Canada Donation Form
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1DONATION FORM
Please print and complete this form then mail or fax to:
Mail: Parkinson Society Canada 316-4211 Yonge St, Toronto, ON M2P 2A9
Fax: 416-227-9600 (Attn: Donations)
Telephone: 1-800-565-3000 or 416-227-9700
DONATION TYPE
General donation (one-time gift)
Monthly donation
In memory of: _________________________________________________________________________
In honour of: _________________________________________________________________________
DONOR INFORMATION
Organization Name (if applicable): ____________________________________________________________
Mr.
Mrs.
Ms.
Miss
Dr.
Other: __________
First Name: _______________________________ Last Name: ____________________________________
Address: ________________________________________________ Suite: __________________________
City: ____________________________ Province: ______________ Postal Code: ____________________
Telephone: _______________________________ E-mail: ________________________________________
DONATION DETAILS
$100
$75
$50
$25
$10
Other: $ __________
Cheque (please make cheque payable to Parkinson Society Canada)
Visa
MasterCard
American Express
Credit Card #:__________________________________________________ Expiry Date: _________________
Name on Card: ____________________________ Signature: ______________________________________
An official tax receipt and acknowledgment will be issued for all donations of $20 or more, or upon request.
MONTHLY DONATIONS ONLY
OPTION 1
Please withdraw the amount above from my bank account each month. I have enclosed a VOID cheque.
OPTION 2
Please charge my credit card each month for the amount indicated above. My credit card number is above.
ACKNOWLEDGMENT CARD
If donation is in memory or in honour, please send acknowledgment card to:
No card required.
First Name: _______________________________ Last Name: ___________________________________
Address: ________________________________________________ Suite: __________________________
City: ____________________________ Province: ______________ Postal Code: ____________________
Personal Message: ________________________________________________________________________
Yes, Parkinson Society Canada can provide my name and address to the recipient of this card.
Parkinson Society Canada strives to provide a brighter future for Canadians today and a world without Parkinson’s tomorrow.
We are only able to do this with the support of generous individuals, corporations and foundations across Canada. If you
would prefer to not receive updates from us in the future, please check this box.
Charitable Registration Number: 10809 1786 RR0001
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