Seat Naming Campaign

DONOR INFORMATION (please print)
Please complete one form for each seat purchased

First name:
Last name:
Address:
City:
Province/State:
Postal/Zip Code:
Home Phone:
Business Phone:
Cell Phone:
Email:
 

Please Put The Following Message on My Plaque

maximum 60 characters, 20 per line
 

Please specify where you would like to purchase a seat:
in the Aquatics Centre
in the Arena.

Pledge Information

Please accept my (our) gift of $500
Please list my gift as an anonymous donation

Total Pledge $ amount enclosed $ remainder pledge $

The remainder is to be paid as follows over a maximum of 2 years,
beginning: Start Date  

$ - 20

$ - 20

Payment Information

Cardholder's Name:
Card Number:
Card Type:
Card Expiration:
/
Card Security Code:

Please process payment beginning and thereafter monthly quarterly yearly other

Thank you for your support.







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