Tamara's House, Services for Sexual Abuse Survivors Inc.
Donation Form

1. Donor Information

*Title:

*First name:

*Last name:

*Address:

*City:

*Province or State:

*Postal Code or Zip:

*Country:

*Phone number:

*Email address:

How you heard about us:

Please send a tax receipt. Yes          No

2. Payment Information
*Donation Frequency

I would like to make a one-time donation of:
I would like to make a recurring monthly donation of:

*Donation amount:
$

*Name on Credit Card:

*Credit Card Number:
*Type of Card
Amex
MC
Visa

*Expiry Month:

*Expiry Year:

*CVS Number:

Direct Debit

*Bank Account Number:

*Institution Number:

*Transit Number:

DISCLAIMER: Direct Debits may be drawn from Canadian bank accounts only

Funds will be withdrawn on the 15th on the month.

3. Tribute Information

Note: For a gift in honour or in memory, please provide the name and (if possible) the address of the person who should be notified of your donation.
My donation is

In honour of:
In memory of:
Not a tribute gift.

Their first name:

Last name:

Address:

City:

Province or State:

Postal Code or Zip:

Country:

  

Name of person to be notified of your donation:


Address of person to be notified (if you have it):
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5. Process Donation
 

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