MOVEMBER +

DONATION FORM

JAIME SORGENTE
Registration 260164
*260164*

IMPORTANT USE THIS FORM TO SEND IN THE MONEY
PLEASE READ THIS INFORMATION
BEFORE COMPLETING THE FORM.
YOU HAVE RAISED OFFLINE.
NEED HELP? CALL: 888 255 0333
Please follow these steps:
STEP 01
You keep the cash you have raised but you
must remit the money to Prostate Cancer
Canada by either a bank deposit, electronic
transfer, cheque, money order or provide your
credit card details in this form.
STEP 02
Complete this form and the Receipt Request
Form for any of your donors that want
a tax receipt.
STEP 03
Mail this form, {with your Receipt Request
Form and cheque / money order}
(if applicable) to:
Prostate Cancer Canada
145 Front Street EAST, Suite 306
Toronto, Ontario, M5A 1E3.

PLEASE COMPLETE
DONATION AMOUNT (NUMBERS ONLY) PAYMENT METHOD (MARK WITH AN X IN THE CORRECT BOX)

.

BANK
DEPOSIT
ELECTRONIC
FUNDS TRANSFER X X X CREDIT
CARD X CHEQUE/MONEY
ORDER

OPTION A BANK DEPOSIT BANK DETAILS

BANKING INSTITUTION ACCOUNT NAME BRANCH ACCOUNT NUMBER
TD CANADA TRUST PROSTATE CANCER CANADA 0241 7808 5217818
PLEASE ATTACH CONFIRMATION RECEIPT TO THIS FORM
OPTION B ELECTRONIC FUNDS TRANSFER DATE OF TRANSFER

MM
/
TRANSFER REFERENCE
D D
/ Y Y

OPTION C CREDIT CARD AMOUNT TO BE DEBITED CARD TYPE VISA AMEX MASTERCARD

$ . X X X
CREDIT CARD NUMBER

EXPIRY DATE

MM / Y Y
CARDHOLDER FIRST NAME

CARDHOLDER LAST NAME

OPTION D CHEQUE/MONEY ORDER PLEASE MAKE PAYABLE TO: PROSTATE CANCER CANADA- MOVEMBER AND BE SURE TO INCLUDE IT WITH THIS
FORM WHEN YOU MAIL IT IN.
TO: PROSTATE CANCER CANADA, 145 FRONT STREET EAST, SUITE 306, TORONTO, ONTARIO M5AIE3

ISSUED BY THE MOVEMBER FOUNDATION 888 255 0333 WWW.MOVEMBER.COM INFO.CA@MOVEMBER.COM

+ CAN MOV 2009 037311_00Q4CE +

TAX RECEIPT INFORMATION
NOTE: IT IS THE DONOR’S RESPONSIBILITY TO BE IN COMPLIANCE WITH THE INCOME TAX ACT AND POLICIES OF CANADA REVENUE AGENCY.