NAME:   MR.   MRS.   MS.   MISS___________________________________

BUSINESS NAME (IF APPLICABLE):_____________________________________

ADDRESS:____________________________________________________________

CITY/PROV:_______________________________POSTAL CODE:______________

TELEPHONE:(       )_________________________

By making pre-authorized monthly donations, you help reduce administrative costs. This means more of your donation is used for research and education.

  VISA                        MASTERCARD                        CHEQUE

Card No.:__________________________________Card Expiry Date:_____-_____

Name on Card:__________________________Signature:________________________

Donation Amount:    $30        $50        $100        $200        Other _________

OR

I prefer to make a monthly donation of $_____________

I would like to make my donation by credit card

I would like to make my donation by checking account (voided check enclosed)        
Tax receipt requested.