| Donation Form |
Please complete the form below and return via mail to:
Administration Autism Centre of Canada P.O. Box 198 Bothwell, Ontarioby Credit Card
Card Number_______________________________
Expiry Date______________
Signature _______________________________________________________________
by cheque (Payable to Autism Centre of Canada – one-time gift only)
Donor Information:
Name____________________________________
Address__________________________________
Apt./Suite__________________
City______________________________________
Province____________________
Postal Code________________________________
E-mail_____________________
Special Donations (Optional):
I wish to make this donation...
I would like to have an acknowledgement sent to:
Name____________________________________
Address__________________________________
Apt./Suite___________________
City______________________________________
Province____________________
Postal____________________________________
Privacy Statement: Autism Centre of Canada respects your privacy. We protect your personal information and adhere to all legislative requirements with respect to privacy. We do not rent, sell or trade our mailing lists. The information you provide will be used to issue tax receipts and to keep you informed about our activities, including programs, services, special events and fundraising activities. If at any time you wish to stop receiving this information, simply contact us via e-mail info@autismcentreofcanada.org
