Donation Form

Please print and complete the following information.

By providing this information you consent for the Canadian Breast Cancer Foundation (CBCF) to collect, disclose, and use it for follow-up contacts, statistical purposes, and to process and recognize donations. Information will be disclosed to employees and agents of CBCF as necessary to accomplish these purposes. Name, and contact information are optional. If you do not wish to be identified please enter “Anonymous” for both the first and last name. Tax receipts cannot be issued to anonymous donors.

Title __________
   
First Name ________________________________________
   
Last Name ________________________________________
   
Organization Name
(if applicable)		 ________________________________________
   
Address Line 1 ________________________________________
   
Address Line 2 ________________________________________
   
City ________________________________________
   
Province __________
   
Postal Code __________
   

Please provide us with a phone number or e-mail address to ensure we have a means of contacting you if we have a question regarding your donation.

Phone Number (_____) _____-______ Ext._____
   
Fax Number (_____) _____-______
   
E-mail ________________________________________
   

I would like to make a donation to the Canadian Breast Cancer Foundation in the amount of (circle one or fill in your desired amount):

$20 $35 $55 $100 Other: $_____
         

I would like my donation to be (circle one): One-time donation / Monthly donation*

*For monthly donations, please attach a cheque marked VOID.

Payment method (circle one):

Visa MasterCard Amex Cheque Cash
      (make payable to "Canadian Breast Cancer Foundation")  

Credit card payment information:

Card Number ________________________________________
   
Expiry Date _____/_____
   
Signature ________________________________________
   

Forms can be mailed/faxed to your nearest CBCF location, provided below:

Canadian Breast Cancer Foundation
Central Office
375 University Avenue, 6th Floor
Toronto, Ontario M5G 2J5
Fax: 416-596-7857

Canadian Breast Cancer Foundation
Prairies/NWT Region
10665 Jasper Avenue, Suite 700
Edmonton, Alberta T5J 3S9
Fax: 780-451-6554

Canadian Breast Cancer Foundation
Atlantic Region
5251 Duke Street, Suite 417,
Halifax, Nova Scotia B3J 1P3
Fax: 902-422-5523
(Note: Atlantic Region represents Newfoundland, Nova Scotia, P.E.I., New Brunswick)

Canadian Breast Cancer Foundation
BC/Yukon Region
300–1090 West Pender Street
Vancouver, British Columbia V6E 2N7
Fax: 604-683-2860

Canadian Breast Cancer Foundation
Ontario Region
20 Victoria Street, 6th Floor
Toronto, ON M5C 2N8
Fax: 416-815-1766

Thank you for your support.

Imagine a future without breast cancer...

 

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