General Donations

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* First Name:
* Last Name:

* Organization:


	Home Work


* Address:

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

I give Lamprey Health Care permission to contact me by email.
I give Lamprey Health Care permission to contact me by mail (post).

Pay using Credit Card
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Payment Method:	One Time Payment Credit Card
* * Donation Amount:	$5,000.00 $2,500.00 $1,000.00 $500.00 $100.00 $50.00 $25.00 Other
Did you know that by covering the processing fee, Lamprey Health Care will be able to help more people?
I want to cover the fees for my donation ( %ProcessingFee% ).

* Processing Date:
* Number of Installments:
	installments
Pay using PayPal
* Credit Card Type:
* Credit Card Number:
* Card Security Number:	Where is my Card Security Number?
* Cardholder's Name:
* Credit Card Expiration:



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