Donation Form

* Required Fields

Donation and Tribute Notification

Amount

Type of Donation

One Time Donation
Recurring Donation

Frequency

Complete the following fields if this gift is a tribute. (optional)

Type of Tribute

Message

Tribute Name

Send notification of this gift to: Title

First Name

Last Name

Address

Address 2

City

State/Province

Zip/Postal Code

Apply your donation to:

Donor Contact Information
Title (Mr/Ms)
* First Name
* Last Name
Company Name
* Address
* City
* Province
* 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 Lung Cancer Canada and I will donate $0.00. No. I will donate $0.00 and Lung Cancer Canada will cover the processing costs.

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
* Postal Code
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.

Politique de confidentialité
Nous prenons des précautions pour protéger vos informations. Nous collectons des informations de carte de crédit ou de compte bancaire, des noms, adresses et autres données liées à votre transaction lorsque vous effectuez un paiement via notre site. Nous utilisons ces informations pour traiter votre paiement.

Termes et conditions
En soumettant votre paiement, vous nous autorisez à débiter le compte ci-dessus du montant spécifié dans le champ Montant de la transaction. Les informations de compte pour les promesses récurrentes/dons mensuels sont cryptées et stockées en toute sécurité via SafeSave™ pour le traitement automatique de vos futurs paiements. Informez-nous à tout moment si vous souhaitez mettre fin à votre engagement.