Donation Form

In memory of Tony Cinquino
En mémoire de Tony Cinquino

Tony touched us all more than he will ever know, and we are truly blessed to have had him in our lives.

Carry his memory with you always. For he will always be in our hearts.

Heaven has gained one incredible angel.

Your donation will help AMI-Quebec support families who have a loved one living with mental illness. All our programs are free and you are helping to keep them that way. Thank you for your donation.

Votre don aidera AMI-Québec à soutenir les familles dont un proche vit avec une maladie mentale. Tous nos programmes sont gratuits et vous contribuez à les garder ainsi. Merci pour votre don.

Montant du don/Donation Amount

Si vous avez un message que vous aimeriez envoyer à la famille de Tony, veuillez l'écrir ici/If you have a message you'd like to send to Tony’s family, please enter it here.

Nous allons aviser Terri (la femme de Tony) par courriel. Si vous souhaitez que la carte soit destinée à quelqu'un d'autre aussi, entrez son e-mail ici. We will notify Tony's wife Terri by email. If you want the card to also go to someone else, enter their email here.

Information/Contact Information

Prénom/First Name

Nom de famille/Last Name

Adresse/Address

Ville/City

Province

Code postal/Postal Code

Téléphone/Phone Number

Nous aimons tenir nos donateurs informés de nos programmes et services.
Comment aimeriez-vous avoir de nos nouvelles? (en anglais seulement)
We like to keep our donors informed about our programs and services.
How would you like to hear from us?

Paiement/Payment Information

Options de paiement/Payment Options

Carte de crédit/Credit Card Information

Titulaire de la carte/Card Holder Name

Numéro de carte/Card Account Number

Date d'expiration/Expiration Date

Code de sécurité/Security Code

Adresse de facturation/Billing Address

Comme ci-dessus/Same As Above

Adresse/Address

Ville/City

Province

Code postal/Postal Code

Pays/Country

Téléphone/Phone

Privacy Policy
We take precautions to protect your information. We collect credit card or bank account information, names, addresses, and other data related to your transaction when you make a payment through our site. We use this information to process your payment. We never share, trade, or sell donor information.

Terms/Conditions
By submitting your payment, you authorize us to charge the account above for the amount specified in the Transaction Amount field. Account information for Recurring Pledges/Monthly Giving is encrypted and stored securely via SafeSave™ for automatic processing of your future payments. Notify us at anytime if you wish to discontinue your pledge.