Tribute

How to make a tribute donation by Fax or Mail?

Mail or fax the form to:

Epilepsy Canada
National Office
2255B Queen St E, Suite 336
Toronto, ON M4E 1G3

Fax:(905) 764-1231

DONOR INFORMATION

Full Name: *

Address: *

City: *

Province:*

Postal Code: *

Phone:

Fax:

Email:

Epilepsy is on the attack. We must strike back!

DONATION INFORMATION

Donation Amount: *
$1000 $500 $250 $100 $50 $35 Other: $

I would like to make my donation in tribute of:*

I would like an acknowledgement card sent to:*
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Please fill in your credit card information below.

Payment Method: *

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Card Number: *
Expiry Date: *

*Signature:

To receive receipts for donations under $15, please check the box.

* Required Fields


		Please send me information about epilepsy: General Parents/Kids Teens Seniors Lumina (News Bulletin)

Registered Charity Business Number: 13117 6042 RR0001

Contributions are tax deductible to the extent permitted by law.

Thank you for being so thoughtful.
Your gift to Epilepsy Canada is truly appreciated.

Epilepsy is on the attack. We must strike back!