__
Yes, I would like to send a donation of support
__ Yes, I would like to become a member of the PHCHCC
and include a $1 fee
__ Yes, I would like to be on your mailing list for information
Enclosed
is a (please check) Cheque ___ or Money Order___ (DO NOT SEND CASH)
For the amount of $_______________
To receive NO tax deductible receipt please print on the the Payee
line -
The Port Hope Community Health Concerns Committee
Or
To receive a tax deductible receipt
please print on the Payee line -
The Uranium Medical Research Centre or
The UMRC
Also
please print Port Hope Biological Studies
Project on
the explanation line
bottom left, or anywhere on the face of cheque or on the back of
cheque.
Then mail to donation cheque and form attached below to :
The
Port Hope Community Health Concerns Committee
Box
476, Station Main
Port Hope, Ontario, Canada
L1A 3Z3
The Port Hope Community Health Concerns Committee
thanks you for your
generosity and support.
--------------
detach here and mail this form below in with
your donation -------------
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