Canadian Injured Workers Alliance Donation Form

Please print this donation form and mail it to us at:

The Canadian Injured Workers Alliance:
1201 Jasper Drive
Thunder Bay, Ontario
Canada
P7B 6R2

Charitable Registration Number: 89426 2385 RR001


Please indicate with a 'X' the amount you would like to donate:

$5  _____

$10 _____

$20 _____

$50 _____

Other (please specify): __________

Please fill the table below with information about yourself:

Name:

  

Address:

  

City:

  

Province/State:

  

Postal/Zip Code:

  

Phone Number:

  

Email Address:

  

Date:

  

Please indicate with an 'X' how you will be paying and if a reciept or invoice is required:

Cash _____

Cheque or Money Order _____

Reciept? _____

Invoice? _____

Thank you for your donation. Your generosity is greatly appreciated.