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4MY Canada Secure On-Line Donation Form
Personal Information
First Name
*
Last Name
*
Street Address
*
City
*
State / Province
*
Postal Code or ZIP
*
E-mail Address
*
Phone (without dashes):
Credit Card Information
Name on Card
*
Credit Card Type or Visa/Mastercard Debit
*
Visa
MasterCard
AMEX
Credit Card Number
*
Expiration Date (mm/yy)
*
Security Code (On back of card.)
*
Donation Amount / Type
Amount
*
Donation Type
*
Special Donation
Monthly Partner Sign Up
Monthly Partner Renewal
Gift designation:
*
Area of Greatest Need
Don't Delete Parents
Justice Wall / Life Room
Staying Connected
Would you like to receive updates from MY Canada by e-mail?
*
I already receive e-mails from MY Canada.
Yes please.
No thank you.
Please let us know if you have any comments or questions.
Thank you for your kindness in donating to the work of MY Canada. If you have any questions do not hesitate to contact us at admin@4mycanada.ca. God bless you. www.4mycanada.ca