Scholarship Fund Donation Form

Required fields are marked with *

DONATION INFORMATION

Member
Non-member

Donation Amount: *	$25 - 1 Ticket $50 - 3 Tickets $100 - 8 Tickets $250 - 25 Tickets $500 - 60 Tickets
Would you like your name entered into the raffle? *	Yes No

CONTACT INFORMATION

First name: *
Last name: *
Company: *
Address: *
City: *
Province: *	Please select a province... Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Postal Code: *
Email: *
Phone: *

PAYMENT INFORMATION

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Total amount donated:
Name on Card: *
Card Number: *
Card Number: *
CVC: *
Expiration (MM/YYYY): *	/

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