Donation Form

White Rock Come Share Centre
15008 - 26th Avenue
Surrey, BC V4B 2R4



[  ] Yes! I would like to support the Come Share Society in their efforts to help those seniors in need envision a future, reclaim self-dignity and achieve the impossible

[ ] I would like to give a donation gift amount.     [ ] $25     [ ] $50     [ ] $75     [ ] $100   [ ] $250   [ ] $500   [ ] ________ Other

OR

[ ] I would like to become a monthly donor.     [ ] $10     [ ] $20     [ ] $30     [ ] $40     [ ] $50     [ ] ________ Other     (Please enclose a void cheque if you wish to become a monthly donor by automatic bank transfer)

Full Name:  _____________________________________

Address: _________________________________________________________________________

City: ______________________  Prov: __________________  Postal Code: _____________

Phone: _____________________  Business: ______________  Email: ___________________

We do not collect, use or disclose your personal information unless you have provided your consent. Information will be used for the purpose of processing and receipting a donation, recognizing a contribution or responding to your request for information