Pages - Home

Donation Form

Personal Information

Title *:	Mr.Mrs.Ms.
First Name *:
Last Name *:
Mailing Address *:
P.O. Box:
City *:
Province *:
Postal Code *:
Home Telephone *:
Other :
Email :
I prefer that my donation remain anonymous

Your donation
Donation Amount *:	$500$200$100 $75$50Other
	dollars
Intent your donation *:
Please specify the reason of your donation *

Name of Honoree

Title :	Mr.Mrs.Ms.
First Name :
Last Name :
Mailing Address :
P.O. Box :
City :
Province :
Postal Code :
Home Telephone :
Other :

Method of payment
Credit Card Payment :	VisaMastercardAmexBy cheque

Credit Card Number
Expiry Date	(mm/yy)
Card holder's Name

Subscription
Yes, I would like to receive further information by email.
I prefer receiving information by regular mail.


Hawkesbury & District General Hospital Foundation 1111 Ghislain Street Hawkesbury, ON K6A 3G5
Charitable Registration Number: 11892 1592 RR0001