Monthly Donation
  Title:  
  First Name:  
  Middle Name:   (Optional)  
  Last Name:  
  Address:  
     
  City/Town:  
  Province/State:  
  Postal Code:  
  Country:  
  Telephone:   (Optional)  
  Email:  
       
  I would like to receive my correspondence in :
  English
French		    
   
  I wish to remain anonymous
       
  I would like to make a monthly contribution of:
  $5 $21*  
  $10 $35  
  $15 $30  
    Other:  $   
* Donors in this category becomes members of the Governors' Circle.
     
  On the:    
  1st of the month    
  15th of the month    
       
  I want to make a gift through the Tribute Program
  In Memoriam    
  In Honour    
   
  This gift is in memory of:
        Full Name:  
   
  Please notify :
        Full Name:  
        Address:  
     
        City/Town:  
        Province/State:  
        Postal Code:  
   
  Send correspondence in:
        English       French    
     
   
  This gift is in honour of:
        Full Name:  
        Address:  
     
        City/Town:  
        Province/State:  
        Postal Code:  
   
  Send correspondence in:
        English       French    
   
  On the occasion of:
         a birthday
         a baby
         a get well wish
         a wedding anniversary
         an anniversary of a transplant
         other:
   
   
  Please designate this gift to:
   Priority Needs
   Other:
   
  Payment method:
  Credit card    
  Debit to bank account  
   
             
   
  Cardholder's name:
  Card number:
  Expiry date:  /   (MM/YY)
   
     
  Institution Name:
  Branch Name:
  Cheque ID:   |||||||   ||||||  
     
  Example:  
 
   
   
 

Comments:
 
 
   
 

I would like more information on:
   The Governors' Circle.
   Bequests, Life Insurance, Gifts of listed securities.
   Gifts from Foundations, Associations and Corporations.
   The Friends of the Vic Monthly Giving Program.

        
Governance / Accountability / Performance
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