wunhcr - UNHCR Canada

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WUNHCR The UN Refugee Agency DONATION FORM

D Mrs. D Ms. D Mr. D Dr. First name:...............................................................................................

Last name:...........................................................................................................

Address·................................................................................................................................................................................................................................................... City·..............................................................................

Province:..................................................................

Telephone:...................................................................................

Postal code:............................................

Email address:........................................................................................................................

SINGLE GIFT

D S5o D s15 D $100 D $250 D My choice:$................ D Cheque to: UNHCR Canada D Cash D Credit card: D Visa D MasterCard D American Express Card number: ........................................................................................... Expiry date: .............. /................. MM

Name on the card:..................................................................................................................

YY

Signature :.................................................................................

MONTHLY GIFT

D s10 D s15

D My choice:$................ Please process my monthly donation starting this date: D 1st of the month D 15th of the month D Bank account (I have enclosed a VOID cheque) D Credit card: D Visa D MasterCard D American Express Ds20

Ds25

Card number: ........................................................................................... Expiry date: .............. /................. MM

Name on the card:...................................................................................................................

YY

Signature :.................................................................................

UNHCR Canada 2 st Claire Ave W, suite 802, Toronto, ON M4V 1L5