Le Bon Dieu dans la rue 895, rue de la Gauchetière West Level 90, Suite 220 Montréal, QC H3B 5K3
	Mail Donation Form Title:      ( ) Ms.        ( ) Mrs.        ( ) Mr. Last name: _________________________________________ First name: _________________________________________ Address: ___________________________________________ City: ______________________________________________ Province: _________________ Postal Code:_____________ Telephone: (________)_______________________________ Email: _____________________________________________ Dans la rue Donors Circle Donations of $250 and more will be listed in a donor booklet. Do you want your name to appear? ( ) YES      ( ) NO I wish to make a donation of: ( ) $50    ( ) $75    ( ) $100    ( ) $250    ( ) $500 Other Amount: $________________ Payment type: ( ) Cheque - please make payable to Dans la rue ( ) Credit Card Card type: ( ) Visa ( ) Master Card ( ) AMEX Card number:_______/_______/_______/_______ Expiry date:________/________ Signature:____________________________________ Monthly Donation Options: ( ) Post-dated Cheques: Enclosed please find ________ cheques for a total donation of $_________ ( ) Credit Card Deduction Amount per month: $________ Start Date: ________/________/________ End Date: ________/________/________		This is a donation: (  ) In memory of: Name: _______________________________ (  ) In honour of: Name: _______________________________ Please notify: Last name: ___________________________ First name: ___________________________ Address: _____________________________ City: ________________________________ Province: _________ Postal Code:________ Telephone: (_____) ____________________ Dans la rue does not solicit door to door or use telemarketing to raise funds. We send receipts for donations of $15 or more. Dans la rue's federal registration number is 13844 9020 RR0001