Brock University Donation Form

Tribute Information

Honoree name

Message to Charity (Optional)

I would like to send a card

Select an E-Card

Select a card

Sender details

Sender name

Sender email

Recipient details

Recipient name

Recipient email

Card Message (Optional)

I would like to send the E-card on a future date

First Name

Last Name

Recipient address (line 1)

Recipient address (line 2) (Optional)

Country

Province

State

City

Postal Code

Phone Number

Email Addresss

Donor Information

Name

First Name

Surname at Convocation (Optional)

Middle Name (Optional)

Last Name

Organization Name

Contact Information

Address 1

Address 2 (Optional)

Country

State/Province

State

State/Province

City

Postal/Zip Code

Phone Number (Optional)

Email Address

I allow Brock University to contact me by email

I allow Brock University to contact me by mail

Additional Questions

My affiliation to Brock University (select all that apply)

Brock alumni
Brock faculty/staff
Current Brock student
Parent of Brock student/alumni
Retired faculty/staff

* Have you considered a legacy gift to Brock?

I have already included Brock University in my will.
Yes, please contact me with more information.
No, I am not interested at this time.

* Please select the designation of your gift:

Do you wish to give your gift anonymously?

Yes, I wish to remain anonymous.

Matching Gift

Enter the name of your employer to see if your company will match your gift.

Sorry, no results were found. Please check the spelling and try again.

Sorry, the Search has timed out.

Payment Information

Card Holder Name

Card Number

Expiry MM

Expiry YY

CVV (?)

Bank Name

Bank ID

Cheque Number

Transit Number

Account Number

Donation Amount