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Please mail or fax your gift to:
Canadian Crossroads International
317 Adelaide St. W, Suite 500
Toronto, ON M5V 1P9
Fax: 416.967.9078
Donation Form
Would you like to make your gift a tribute?
Please complete the section below.
Please select one of the following:
q In Honour of:
q In Memory of:
Name:
Please send Tribute Notification to:
Name:
Apartment/ Suite:
I would like to become a Global Citizen.
Address: Enclosed is my one time gift of: q $100 Friend q $500 Supporter
q $250 Benefactor
q Other $
q Mr. q Mrs. q Ms. q Dr. q Other
First Name:
Last Name:
Apartment/Suite:
Address:
City: Province/ State:
Postal/ Zip Code:
Please make cheque payable to Canadian
Crossroads International, or complete the
credit card section below.
Credit Card Type:
q Visa q MasterCard q AMEX q Diners Club
Number:
Expiry Date (mm/yy):
Name on Card:
City: Province/ State: Postal/ Zip Code: Phone (h):
(w): Email:
Today’s Date (dd/mm/yyyy):
Cardholder’s Signature:
q I would like my gift to be anonymous.
q This gift will be matched by my company.
q I would like to receive information about making a
bequest to Canadian Crossroads International.
Thank you for your gift.
Together we can create ONE WORLD where human rights are respected, poverty is eliminated and
the impact of HIV/AIDS is reduced.
Canadian Crossroads International, 317 Adelaide St. W, Suite 500, Toronto ON, M5V 1P9
Toll Free: 877.967.1611 ext. 0, in Toronto 416.967.1611 ext. 0, Email: [email protected]
Charitable Business Number 12981 4570 RR0001
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