General Donations

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* denotes required information

Make a personal donation:
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* First Name:
* Last Name:

* Organization:

Contact Information


	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).
I give Lamprey Health Care permission to contact me by phone.

Payment Information

Pay using Credit Card
Card Security Number is not supported in data entry. To process a credit card payment, you need to disable Card Security from the Electronic Payment page in the Configuration tab.
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:

Security Check

We have implemented an extra step in order to prevent Credit Card fraud. Unfortunately, some people use automated programs to test whether fraudulently obtained credit cards are valid. To counteract this practice we ask that you answer the question below.