DONATION FORM

 r   YES!  I would like to support patient care in my community. 

 Name:                                                                                                                                   

 Address:                                                                                                                               

 City:                                         Province:                          Postal Code:                                  

 Telephone:                                Fax:                                 E-Mail:                                           

Gift Amount:

r $35

r $50

r $75

r $100

r I prefer to give $____________

r   My cheque/money order is enclosed, made payable to: Lambton Hospitals Foundation

r   I prefer to use my:     r VISA            r Mastercard

Cardholder’s Name:                                                                                                                

Card Number:                                                                                                                        

Expiry Date:                           Cardholder’s Signature:                                                             

Please direct my gift to:

r Priority Needs

r I prefer to direct my donation to:                                                                                                                                                      (your program/department of choice)

If your gift is a tribute or memorial, please complete the next section:

My gift is a:    r Tribute       r Memorial

In honour or memory of:

Name:                                                                                                                                   

Acknowledgement letter to be sent to:

Name:                                                                                                                                   

Relationship to remembered person (e.g. wife/husband, son/daughter, etc.):                                

Address:                                                                                                                               

City:                                         Province:                          Postal Code:                                  
 

r Please send me information on making a gift in my will.

r Please send me information on making a monthly donation.

Please fax this form to Lambton Hospitals Foundation at (519) 336-8780.
Or mail this form along with your cheque or money order to:
Lambton Hospitals Foundation
89 Norman Street, Sarnia, ON,  N7T 6S3
For more information, please call (519) 464-4408 or email [email protected].
Charitable Business Number:  86939 4163 RR0001

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