Cornwall Community Hospital Foundation
Donation Form


Click here
for more info about making a donation
If you would like to make a donation, please fill out the following form. Once complete, you can print it and send it (by fax or mail) to the Foundation, or you can simply e-mail us the information by pressing the "Submit Donation Form" button at the bottom of page.

Your Information
Title: Mr.   Mrs.   Ms.  
First Name:
Last Name:
Address:
City:
Province:     Postal Code:
Phone:
E-Mail:

Donation Information
Donation Amount

Please direct my donation to:
Wherever the money is most needed
Specific Area
Specific Event
      If I selected Radiothon above, please contact me as I would like
           more information on becoming an AM 1220 12 x $20 Friend!

Recognition Information
In Memory of   In Honor of   Speedy Recovery
Name of Honoree:
(Please indicate who we can notify of the gift)
Name:
Address:
City:
Province:
Postal Code:

Lasting Contributions
I / We have made a provision for a bequest in our will.

Payment Information
Cheque *
 VISA
 MasterCard
Credit Card Number       Expiry Date:
Cardholders Name
Signature __________________________________________________
Only necessary if mailing or faxing this form.
* You can print this completed form and mail it with your cheque payable to:

Cornwall Community Hospital Foundation
840 McConnell Avenue
Suite 2703
Cornwall, Ontario
K6H 5S5

or fax to (613) 930-4509



www.OurHospitalOurFuture.ca