Page 8 - Wellspring 30/30 Vision Campaign

30/30 VISION CAMPAIGN PLEDGE FORM

 Individual  Organization
Name: ______________________________________________ Position: _____________________________________

Organization Name: __________________________________ Address: _____________________________________
City: ___________________________________ Province: ____________________ Postal Code: __________________

Phone: _________________________________ Email: _____________________________________________________

I/We agree to make the following pledge toward Wellspring Cancer Support
Foundation’s 30/30 Vision Campaign:

 $30,000  $_______________

Pledge to be paid:  as one-time gift

 over two years, starting with this Pledge Payment: $_______________

PAYMENT METHOD

 Cheque(s) (payable to Wellspring Cancer Support Foundation)
/
 Credit Card:  Visa  MasterCard  Amex Expiry Date: ___________
(MM/YY)
Card No.: _________________________________ Name: _____________________________

 Gift of Stock or Securities (Wellspring will send you information on making a gift of securities)
 Direct Deposit (Wellspring will send you the details you need to make a direct deposit)

RECOGNITION DESIGNATION
WELLSPRING CANCER
SUPPORT FOUNDATION
I/We would like to: I/We would like this 30/30 Vision 105 Wellness Way

 remain anonymous Campaign gift to be recognized at: Toronto, ON M4N 0B1
 be recognized publicly as follows:  Wellspring Westerkirk House 416.480.4440
________________________________  Wellspring Birmingham Gilgan House donations@wellspring.ca
Charitable Registration No:
89272 8940 RR0001
Signature: ___________________________ Date: __________________________