AFT - Formstack

Name*

First Name

Last Name

Date*

Address*

Address Line 1

City

Province

Postal Code

Email*

Phone*

Where would you like your donation to be directed?*

General Fund Staff Support

Other:

If you selected "Other" please specify the fund

Name of Staff Member*

Donation Amount*

25 50 100

Other:

If you selected "Other" please specify the amount above.

Donor Name:*

Please enter the name of the individual or business from which the donation is being made.

Select which day of each month you would like your payment to be processed*

1st of every month 15th of every month

Starting date of automatic funds transfers*

Please specify the date you would like your donation to begin (Either on the 1st/15th).

Ending Date*

When I request a cancellation

Other:

If you selected "Other" please specify the date above

These services are for*

Personal Business

Pre-Authorized Debit Request