Thank you for making a donation to the Heart and Stroke Foundation. If you have any questions please call us at 1-888-HSF-INFO (1-888-473-4636).
2012 Heart Month Campaign I am enclosing a one-time donation of: $35
$50
$100
$250
Other:
Mr.
Mrs.
Ms
Dr.
Other:
First Name: _______________________________ Last Name: Address: _____________________________________________________ Suite: City: ______________________________________ Prov/State: ________ Postal code/ Zip: Country: __________________________________ Home telephone:
Cheque or money order payable to: Heart and Stroke Foundation Please charge the above amount to my credit card (please complete credit card information below)
Credit Card Information: Visa
Mastercard
American Express
Name on card: Card Number: ________________________________________________ Expiry Date: Signature:
Type of Donation: Is your donation sponsoring a specific participant or event?
Yes
No
Name of participant (if applicable): Name of event (if applicable):
Thank you for supporting the Heart and Stroke Foundation. Please mail or fax this form to the Heart and Stroke Foundation office in your province. Mailing and fax information can be found on page 2 of this form.