* Name: _______________________________________________________________________________

* Address: _______________________________________________________________________________

* City: _______________________________________________ * Prov/State: ___________________

* Postal Code/Zip: _____________________________________ Country: ___________________________

Telephone: ( ______ ) ________________________________

E-mail Address: _____________________________________________________________________________
*^{The Canada Customs & Revenue Agency requires that donation receipts bear the name and address of the donor.}

I would like to make a donation to the Canadian AIDS Society to the amount of (tick one or fill in the desired amount):

__$20

__$40

__$60

__$100

Other:$___

Payment method (please tick one):

__Visa

__Mastercard

__Amex

__Cash

__Cheque (Payable to 'Canadian AIDS Society'

Credit card payment information:

Card Number: _____________________________________

Expiry Date (month/year): _____/_____

Signature: _______________________________________

Please indicate if discretion is required for telephone calls or mailings: _Yes _No

We do not sell, trade or otherwise share our mailing lists. We undertake to keep all donors updated on the activities of the Canadian AIDS Society.

Please tick here if you do not wish to receive our occasional mailings: __