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    Monthly Donation Form

    * Required Fields
    Information for Tax Receipt:
    Donor First Name *:
    Donor Last Name *:
    Company:
    Address *:
    City *:
    Province *:
    Postal Code *:
    Phone (xxx-xxx-xxxx) *:
    Fax:
    Email Address *:
    Payment Information:
    Pay By *:
    Card Holder First Name *:
    Card Holder Last Name *:
    Credit Card Number *:
    cvv2 Number *: (The 3 digit # at the back of card)
    Expiry Date(MM/YYYY) *: /
    Donate Amount *: $ /month (no comma please)
    Start Date (DD/MM/YYYY)*: / /
     
    For added security to your on-line donation, please check this box before hitting the donate button.