| Name:
____________________________________________________________ |
| Address:
__________________________________________________________ |
| City:
________________________ Province:
____________________________ |
| Country:
___________________________ Postal Code: __________________ |
| Tel:
__________________________ Fax:
_____________________________ |
| Email:
____________________________________________________________ |
| My previous
donation was : $________ |
Enclosed is
my contribution:  $25 $50 $100
$150 $250
Other: __________ |
| I prefer
to pay by VISA or Mastercard |
Card No.  |
| Expiry Date:
month ________ year ________ |
| Signature:
_______________________________________ |
| Please do
not publish my name on the donor list. |
Please return this form with your tax
deductible donation to:
The Centre for Literacy of
Quebec
2100 Marlowe
Suite 236
Montreal, Quebec H4A 3L5
Tel: (514) 798-5601
Fax: (514) 789-5602
Website: www.centreforliteracy.qc.ca
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