Yes! I
want to help the CAP continue to improve
the quality of life for people affected
by Porphyria!
The Canadian Association for Porphyria is federally registered as a
nonprofit
charity in Canada
(#11883 5305 RR0001). Tax receipts will be issued for
donations over $10.
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Gifts made using Visa or MasterCard can also be faxed to 1-204-476-2800 or mailed to the national office address (below) with this form: |
Donor Information:
Name___________________________________________________________
Address_________________________________________________________
City_____________________ Province___________ Postal Code___________
Phone No_____________________ E-mail Address______________________
Payment Information:
Donation Amount
[ ] $25 [ ] $50 [ ] $100 [ ] $200 [ ] Other______________
Credit Card Type
VISA MasterCard Card Number_________________________
Name on Card _________________________ Expiration Date____________
Signature ______________________________________________________
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Gifts made by cheque (made payable to the Canadian Porphyria
Foundation) should |
P.O. Box 1206
Neepawa, Manitoba R0J 1H0 Canada