Name:________________________________

     Address:________________________________       City:________________________ 

     Province:_________________   Postal Code:________________      Phone:________________

I WOULD LIKE TO SUPPORT

                                     The Brantford General Site            The Willett Site

This is a Memorial Donation    In Memory of:     ________________________________ 

Enclosed is my gift in the amount of:     $20   $35  $50    $100   Other $________

I prefer to use my    VISA     Master Card      AMEX

Card #    ________________________________      Expiry Date ________________________

THANK YOU FOR YOUR HELP!

A tax receipt will be issued for all donations of $20 or greater unless otherwise  requested.