National General

DATE RECEIVED BY

Donation Form PHONE/WALK IN RECEIVED AT

SECTION A: DONATION INFORMATION (Make cheques payable to Canadian Cancer Society.)

Donation made Gift type

Phone In person Daffodil One-time donation Independent fundraising event Tribute gift Other

Event Event name Team name Participant

Donation amount Gift designation Payment method

$100 $75 $50 $25 Cash Cheque/money order Debit card

Other Notes Visa MasterCard American Express

SECTION B: DONOR DETAILS (Required for official tax receipt purposes.)

First Name/Company Name

Last Name

Suite/Apt Street

City Prov Postal Code

Email Phone

Receiptable Non-receiptable Group Fundraising (non-receiptable)

SECTION C: IN HONOUR/IN MEMORY/OCCASION (Complete this section if donation is an in memory, in honour or for an occasion.)

Name of the person that your donation is made In memory In honor

Title First Name Last Name

Occasion type (for gifts in honor)

Acknowledgement card

YES, send an acknowledgement card to the recipient below English French

NO, an acknowledgement card is not required

First Name Last Name

Suite/Apt Street City Prov Postal Code

Message on card

Sign card from

SECTION D: CREDIT CARD INFORMATION (This section to be removed and destroyed once credit card payment has been processed.)

Cardholder name Card number Expiry

Privacy: The Canadian Cancer Society is dependent upon the generous support of donors and volunteers to fulfill its mission. We collect your personal information in order to process your donation, issue a tax receipt, and
provide updates about our impact and other ways to help. Your personal information will not be sold or traded with other organizations. For more information about our privacy practices, view our privacy policy at cancer.ca.

National Office, 55 St Clair Avenue West, Suite 500, Toronto, ON M4V 2Y7 Charitable Registration No. 11882 9803 RR0001 (Canada); 98-6001242 (USA)