MULTIPLEX CAMPAIGN PLEDGE FORM

Please click here to download then print the form in PDF format

Yes, I wish to support the construction of Moose Jaw’s Multiplex Project!

Name: _____________________________________________________________________________

Telephone (day): _______________ (evening): _______________ E-mail:________________________

Address (home): _____________________________________________________________________

Address (business): __________________________________________________________________

City: __________________ Province:_____________________ Postal Code:_____________________

I wish to make a total contribution of $__________, to be paid as follows:

One-time payment

Annual installments of $ _______________ for _______________ years

PAYMENT OPTIONS

By Credit Card Visa Mastercard

Card Number:______________________ Expiry Date:________ Name on card:____________________

By Cheque (reminders will be sent for annual installments) OR Post dated cheques enclosed.

Cheques made payable to the City of Moose Jaw

First installment is enclosed OR

First installment will be paid on ____________/____________/____________ (dd/mm/yyyy)

By cash $_______________

ACKNOWLEDGEMENT

Please acknowledge my contribution in the name(s) of:________________________________________

_____________________________________________________________________________________

I wish my contribution to remain anonymous.

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In the event of changes to my personal circumstances, I understand that I may modify or cancel my pledge at any time.

Signature: ________________________________

Date: ____________________________________

 

Thank you!

Multiplex Builders Inc.

Please make cheques payable to the City of Moose Jaw. The City of Moose Jaw will issue receipts for tax purposes on February 28 in the year following your payment. Tax receipts will be issued only for donations of $10 or more. Completed pledge forms and donations can be dropped off at City Hall, 228 Main Street North, or mailed to Multiplex Builders Fundraising Campaign, Box 881, Moose Jaw, SK S6H 4P5.