Individuals
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corporations
Donation form
First name:
Last name:
Address 1:
Address 2:
City:
Province / state:
Country:
Email:
Telephone :
Would you like to be on our electronic news bulletin mailing list?
Yes
No
May we approach you again next year?
Yes
No
Do you prefer to remain anonymous?
Yes
No
Would you like a receipt for tax purposes?
Yes
No
For a donation of $500 or any multiple, would you like to dedicate your donation and have it published on our website?
Yes
No
Dedication:
If so, would you like us to contact you before the dedicated day?
Yes
No
We respect the privacy of our donors. The names of Dr Clown’s donors will not be divulged to any other organizations or individuals.
Individuals
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