Donation Form

* Required Fields

Contact Information

Legend:	Individual Gift / Corporate Gift
Corporate Gift?
Donor Type

Title
First Name
* Last Name / Company Name
Contact Name (corporate gift)
* Address
Address 2
* City
* Province
* Country
* Postal Code
Home Phone
Cell Phone
Work Phone
* Email

Help Us Cover Costs
Simply leave "Yes!" checked below to ensure that 100% of your intended donation is available for our mission.
Yes! I want $0.00 to go to The Argenteuil Hospital Foundation and I will donate $0.00. No. I will donate $0.00 and The Argenteuil Hospital Foundation will cover the processing costs.

Payment Information
Payment Options

Credit Card Information
Card Holder Name

Card Account Number
Expiration Date
* Security Code The 3 or 4 digit Security Code (CVV2) can be found on the back of your credit card. For American Express, the Security Code (CID) can be found on the front of the card.

Billing Address
Same As Above
* Address
City
Province
* Country
* Postal Code
* Phone
Email

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.

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.