Contribution Form

Please print this form and fax or mail to:

FRIENDS of Canadian Broadcasting
200/238
131 Bloor Street West
Toronto, Ontario
M5S 1R8

Fax: (416) 968-7406

Please make cheques payable to FRIENDS of Canadian Broadcasting. If you prefer to donate by VISA or MasterCard, be sure to include your signature along with the amount of your contribution, your credit card number, and the expiry date.

You can also make your contribution online.

PART ONE

Name: ____________________________________________

Address: __________________________________________

___________________________________________________

Tel: ____________________ Fax: _____________________

E-mail: ____________________________________________

I am already a FRIENDS Supporter. SUPPORTER PIN ___________________________

PART TWO

Please check one.

I've enclosed my cheque payable to FRIENDS of Canadian Broadcasting

     Please charge my:    VISA    MasterCard

            Card # _____________________________________

            Expiry Date _________________________________

Signature ___________________________________

Today's Date ________________________________

I prefer to make monthly donations and have completed PART THREE below

PART THREE

CHEQUING ACCOUNT AUTHORIZATION

I hereby authorize a chequing account deduction of

$5.00 $7.50 $10.00 $______

at the end of each month. I understand that I may cancel this arrangement in writing at any time. (Please mail this form and enclose a cheque marked "void" so that we may make arrangements with your bank.)

Name: ___________________________

Signature: ________________________

or ...

CREDIT CARD AUTHORIZATION

I hereby authorize FRIENDS of Canadian Broadcasting to deduct:

$5.00 $7.50 $10.00 $______

from my credit card on the 15th of each month. I understand that I may cancel this arrangement in writing at any time.

Please charge my: VISA MasterCard

Card # ___________________________

Expiry Date _______________________

Signature _________________________