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Sponsor Returns for Leukemia Bottle Drive

All donations are charged in Canadian dollars.

* denotes required information

Make a personal donation:
Make your donation on behalf of an organization:

* First Name:
* Last Name:

* Organization:


	Home Work

Enter address manually
* Address:

* City/Town:
* Country:
* * * Province/State:
* Postal/Zip Code:
* Phone Number:	( ) Ext.
Cell Phone Number:	( )
* Email Address:
* Confirm Email Address:

I allow The Leukemia & Lymphoma Society of Canada to contact me about its other programs and services.

Display my name on the donor listing. Display Name
Display my donation amount on the donor listing.

Pay using Credit Card
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Payment Method:	One Time Payment Credit Card
* * Donation Amount:	$25.00 $50.00 $100.00 $250.00 $500.00 $1,000.00 Other
By helping to offset the transaction cost of your donation, The Leukemia & Lymphoma Society of Canada will be able to help more people.
Yes, I would like to help offset the transaction costs of my donation by adding a $2.00 administrative fee

* Processing Date:
* Number of Installments:
	installments
Pay using PayPal
* Credit Card Type:
* Credit Card Number: Enter your credit card number without spaces.
* Card Security Number:	Where is my Card Security Number?
* Cardholder's Name:
* Credit Card Expiration:
Card Valid From
Issue Number

* Bank Name:
* Bank ID:
* Cheque Number:
* Transit number:
* Account Number: