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ACTSS Donation Form

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First Name:	*
Last Name:	*
Province:	*
City:	*
Address:	*
Postal Code:	*
Phone:	*
Email:	*

Payment Information
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Payment Type:	VISA MASTERCARD *
Credit Card Number:	*
Credit Card Expiry Date:	* *
Tax Receipt?	Yes (available only for donations of $25 or greater) No

Additional Information
Acknowledgement:	Please send acknowledgement to:
Dedication:	This donation is made in honour of:
Referral Source:	Where did you find out about ACTSS?

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