Monthly Giving Donation

Name (required):
Address (required):
City (required):
Province (required):
Postal Code (required):
Phone Number (required):
Email (required):
I/we wish to join Friends of the Foundation and support NBRHC Foundation through monthly donation of (required):---$10$20$25$30 ($1 a day)$50$83.33 ($1,000 per yr)Other Amount
If other, please specify the monthly amount:
This donation is made on behalf of (required):---an Individuala business
Payment method (required):---Bank AccountCredit CardPostdated Cheques
*Please Note:

• Pre Authorized Debits are processed on the 15th day of each month (I may revoke my authorization at any time, subject to providing notice 10 days before the processing date – 15th of the month. To obtain a sample cancellation form, or for more information on my right to cancel a PAD Agreement, I may contact my financial institution or visit www.cdnpay.ca. I have certain recourse rights if any debit does not comply with this agreement. For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit www.cdnpay.ca.).
• Credit cards are processed the first week of the month. We will contact you to get your credit card details.
• Postdated cheques will be processed on the cheque date or the next business day. Cheques can be mailed or dropped off to:
  North Bay Regional Health Centre Foundation Office
  50 College Drive
  North Bay, Ontario
  P1B 5A4
  P.O. Box 2500

Please designate my gift to (required):---Greatest Need FundOther
If other, please specify:
I would like my name to appear as (required): on published donor recognition lists.
Today's date (required):
I acknowledge my intent to participate in the Monthly Giving Donation Program with the NBRHC Foundation.---Yes
Foundation donor list and donor wall recognition:---As an inspiration to others, I agree to allow my name to be added to the Foundation donor list and donor wall.I wish my name to remain anonymous. (Your name will not be added to any donor list).

CHARITABLE NO. # 88773 1123 RR0001

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