Donation Form

DIXIE BLOOR NEIGHBOURHOOD CENTRE

Thank you for all your donations, Your donations will help children in need especially over the holidays.

Donor Information:

Type of donation:	Individual Corporate
First Name:^*
Last Name:^*
	New Born Child Adolescent Adult Seniors
Company Name:
Address:^*
City:^*
Province:^*

Postal Code:^*
Phone:^*
Email:^*

Payment Information: All Money Order/Cheques can make payable to Dixie Bloor Neighbourhood Centre
	Cheque Money Order Cash

Amount:^* (All funds charged in Canadian dollars) $25 $50 $75 $100 Other: $

1420 Burnhamthorpe Rd. East Suite 315 Mississauga,
ON, L4X 2Z9
Tel: (905) 629 1873 Fax: (905) 629 0791