DOMINO THEATRE FUNDRAISING CAMPAIGN 2010- 2011

                                          DONATION FORM
 

NAME:…………………………………………………………….


ADDRESS:………………………………………………………….

 
        ……………………………………………………………
           

PHONE #…………………………………………………………….


E-MAIL………………………………………………………………….

 
I am pleased to donate/pledge the following total amount to Domino Theatre’s fundraising:

 

$………………………………………..

To:
Domino Theatre Inc:
Box 884,
Kingston K7L 4X8

  

This donation/pledge to be paid as follows: $………………………..now

 
And the following amounts in each of the following years:  

$……………. In 2011 $…………..in 2012, $………………in 2013, $……………..in 2014 and $……….in 2015

  

IF PAYING BY CREDIT CARD
 

Please note credit card type………………………………………………………………

 
Credit Card Number………………………………Expiry Date…………………………
 
 

Signed:                                                             Date:

 
 

 

For Domino……………………………………………………………………………..