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

I'd like to Volunteer	__________________________
I'd like to Donate $:	__________________________
Name:	__________________________
Organization:	__________________________
Address:	__________________________
Phone:	__________________________
Fax:	__________________________
E-mail:	__________________________
City:	__________________________
Postal Code:	__________________________
Province:	__________________________
Country:	__________________________
Enclosed:	$_____________
Date:	_____________
Signature:	____________________________