Mid Main Charitable Donations Form

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Modified December 2012
midmain.net
Mid-Main Charitable Donations Form
Donations to Mid-Main can be made a number of ways:
1. PayPal – Accessed through our website at midmain.net
2. Debit – In person
3. Cheque or Credit Card (VISA and Mastercard) - complete this form and mail it to
us with your cheque or credit card information. Ensure cheques are payable to:
Mid-Main Community Health Centre and addressed to:
Executive Director
Mid-Main Community Health Centre
3998 Main Street
Vancouver, BC V5V 3P2
Charitable Tax Receipts for donations over $20.00 are mailed out each January for all
donations made in the previous year.
Please tell us how you would like your funds directed:
General Donation
Medical
Dental
Bangladesh Health Project
PAT
Date:
__________________________________________________________
Name:
__________________________________________________________
Address:
__________________________________________________________
City:
_____________________
Prov:
________
Postal:
________
Home Ph:
_____________________ Email: ______________________________
Amount
$ ____________________
 Cheque (enclosed)
 Cash (do not send in the mail)
 Credit Card
 VISA
OR
Mastercard
Name as it appears on the card:
________________________________________
Card # ________________________ Expiry Date: _____________________________
Many thanks for your support from everyone at Mid-Main!

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