DONOR INFORMATIONName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Telephone*Email* TYPE OF GIFTPlease select the type of gift you would like to make with your donation:*Area of greatest needSpecific Fund, Department or Community EventSpecify which Fund, Department or Community Event:*TYPE OF DONATIONPlease select the type of General Donation you would like to make:*A single one time donationMonthly donations (credit card or debit pre-authorized payments) PAYMENT METHOD - Single DonationPAYMENT METHOD - Monthly DonationI would like to make a donation in the amount of:*$1000$500$250$100$50OtherSingle Donation Amount Price: $ 1,000.00 CAD Single Donation Amount Price: $ 500.00 CAD Single Donation Amount Price: $ 250.00 CAD Single Donation Amount Price: $ 100.00 CAD Single Donation Amount Price: $ 50.00 CAD I would like to make a monthly donation in the amount of:*$20$15$10OtherMontly Donation Amount Price: $ 20.00 CAD Monthly Donation Amount Price: $ 15.00 CAD Monthly Donation Amount Price: $ 10.00 CAD Enter your Donation:* Payable on the 1st day of each month. If the 1st is a Saturday, Sunday or statutory holiday, your donation will be processed on the following business day. A receipt for income tax purposes will be mailed to you at the beginning of the next calendar year. You may modify or discontinue your monthly donations at any time. Please inform us by phone at 514-630-2081 at least seven (7) business days before the scheduled date of your next gift, so that we can ensure that no additional donation is processed.PAYMENT METHOD - Monthly DonationPAYMENT METHOD - Single DonationWould you like a tax receipt?*(Please note that for amounts under $25, receipts are sent upon request )YesNoPlease select your preferred method of payment:*Direct DebitCredit CardDirect Debit WithdrawalName of financial institution*Account number*Transit number*Or write a cheque to the Foundation with VOID written on it The Lakeshore General Hospital Foundation 160 ave. Stillview, suite 1249 Pointe-Claire, Québec H9R 2Y2Credit Card PaymentBilling Information* Same address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Credit Card Information* American ExpressMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name Summary**Please confirm that all information is correct.** Name: {Name (First):1.3} {Name (Last):1.6} Address: {Address (Street Address):2.1}, {Address (City):2.3} {Address (State / Province):2.4} {Address (ZIP / Postal Code):2.5} Telephone: {Telephone:3} Email: {Email:4} Type of gift: {Please select the type of gift you would like to make with your donation::16} Donation purpose (if specified): {Specify which Fund, Department or Community Event::17} {Please select the type of General Donation you would like to make::12} Donation amount: {I would like to make a donation in the amount of::38} {I would like to make a monthly donation in the amount of::72} {Enter your Donation::44} Total $ 0.00 CAD EmailThis field is for validation purposes and should be left unchanged.
