COMMUNITY LIVING HURONIA FOUNDATION
339 Olive Street, Midland, Ontario L4R 2R4
Phone: (705) 526-4253 Ext. 221
Fax: (705) 527-4182
E-mail: clhfoundation@clhmidland.on.ca

Dreams to Reality
Annual Campaign Pledge Form
(Please print and mail to above address)

GIFT AMOUNT:
In support of the Community Living Huronia Foundation Dreams to Reality Annual Campaign, I/We hereby pledge: (please choose)

A total gift in the amount of $
I would like to make a one-time gift in the amount of $
I would like to make a monthly gift in the amount of $

Reason for Transaction:

Campaign Donation Memorial Donation
Golf Gala Tickets 
Other: Specify #Tickets

METHOD OF PAYMENT:

Cheque(s) payable to Community Living Huronia Foundation enclosed.
Visa Card NumberExpiry Date
Card holder name/signature:

Please charge the above credit card $ Monthly Quarterly Semi-Annually
Starting Date (DD/MM/YY): Ending Date (DD/MM/YY):

Gift of securities (Please ask Michelle Armstrong @ 705-526-4253 Ext. 221 to contact me with this simple transaction.)

GIFT ACKNOWLEDGEMENT:
I/We understand that we will receive a charitable tax receipt and that my/our gift will be recognized at Community Living Huronia, and wish that it be recognized with the following names(s): (e.g. Tom and Wendy Black or that you wish to remain anonymous):

For memorial donations:

Name of Deceased:
Please notify:

For tax receipts and correspondence should be addressed to:

Name for tax receipt:
Name(s) for correspondence:
Organization:
Address:
City: Postal Code:
Residence Telephone:

Business Telephone:
E-mail Address:

Fax Number:
Signature:

An independent accounting firm audits the Community Living Huronia Foundation each ear, with results published in our Annual Report.  Dedicated business and community leaders sit on our Board of Directors, ensuring accountability and integrity in every activity the Community Living Huronia Foundation undertakes.
Charitable Registration: 86837 - 009 - RROOO1

Thank You