* Required Fields
Complete the following fields if this gift is a tribute. (optional)  
  Type of Tribute 
  Message to be forwarded to the person being recognized in I Made a Difference Program 
  Toronto Challenge Pticipant / Tribute Name 
  First Name 
  Last Name 
  Address 2 
  Zip/Postal Code 

Contact Information
* First Name 
* Last Name 
  Company Name 
* Address 
* City 
* Province 
* Postal Code 
  Home Phone 
  Work Phone 
* Email 

Credit Card Information
  Card Holder Name 
  Card Account Number 
  Expiration Date 
* Security Code  
Billing Address
  Same As Above 
* Address 
* Postal Code 

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Contact Us: Copernicus Lodge Foundation •• 66 Roncesvalles Avenue, Toronto, ON M6R 3A7

•• 416-536-7122, ext. 252 •• foundation@copernicuslodge.com

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