Donation Form I (we) donate a total of $

Please send this Donation Form back to:
The Grand Theatre
Attn: Development Department
471 Richmond Street, London, ON N6A 3E4
Donation Form
I (we) donate a total of $__________________
Donor Information
Name
Street address
City, Postal Code
Phone
Email
I (we) wish to make this contribution in the form of:
___Cheque (enclosed) ___Credit Card (please fill out the information below)
Credit Card Type
Credit Card Number
Expiration Date
Authorized Signature
Please direct my donation to:



Annual Fund
Make A Difference Fund
Capital Fund
Please Use the following name(s) in all acknowledgements:
_____________________________________________________________________________________

Check here if you wish to your gift remain anonymous
NOTES:
_____________________________________________________________________________________
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THANK YOU FOR YOUR SUPPORT!