Pledge Form

Please print and fax to: (705) 726-1076 or mail or bring in person to:

234 Cook St. Barrie On L4M 4H5

In support of the Grove Park Home for Senior Citizens
I/we hereby pledge $________a year for the next ___ (one to three years) for a total gift of $______

Beginning on ___/___/____(mm dd yy)

Cheques may be made payable to: Grove Park Home

I/we wish to make this gift:

q In full at this time

q Annually

q Semiannually

q Quarterly

q Monthly (Pre-authorized monthly payment plans are available - please ask)\

q Cash

q Cheque

q VISA

q Master Card

Signature ____________________ Expiry Date ___/___
Card Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

I/we understand that my/our gift will be recognized at Grove Park Home and wish that it be recognized with the following name(s) (e.g. John & Sally Smith):
______________________________________________________________

For tax receipt and record keeping purposes, correspondence should be addressed to:

Name for tax receipt _____________________________________
Name(s) for correspondence _____________________________________
Address _________________________________________________
_________________________________________________
Postal Code _______________
Telephone (res) (___) ___________ (bus) (___) ___________
(fax) (___) ___________ (email) _____________________

Signature ____________________ Date ________________

Charitable Registration # 132148586RR001
Please return this form to Grove Park Home
Thank You!