Donation Form

Freedom of Choice in Health Care Inc.
Mailing Address: P.O. Box 22100 Belleville, ON K8N 5V7
Office: 444 Dundas St E, Suite H & I, Belleville, ON, Canada K8N 1E9
English/French Tel: 613-771-1797 Fax: 613-771-1435
E-mail: myrights@freedomofchoiceinhealthcare.ca

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      Yes, I'd like to Volunteer!
I would like to Donate $:
Name:
Organization:
Address:
Telephone:
Fax:
E-mail:
City:
Postal Code:
Province
Country:
 
Enclosed: $
Date:
Our Basic Annual Membership Fee
Total to Remit
Individuals $25.00 plus GST* $26.75
Families, & chaptors $45.00 plus GST* $40.15
Businesses & Organizations $100.00 plus GST* $107.00(+ donation)

* Note – no tax for non-Canadian members.

We ask for an additional annual donation based upon gross sales / income.



Check Tier Gross Sales/Income Range Total to Remit
1 $ 500,000+ $ 300 $ 407.00
2 $ 1,000,000+ $ 500 $ 607.00
3 $ 2,000,000+ $ 1,500 $ 1,607.00
4 $ 3,000,000+ $ 2,000 $ 2,107.00
5 $ 5,000,000+ $ 2,500 $ 2,607.00
6 $ 10,000,000+ $ 5,000 $ 5,107.00