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Donation Information
  Type of Donation 
Complete the following fields if this gift is a tribute. (optional)  
  Type of Tribute 
Unless otherwise specified, gifts will go towards area of greatest need.  
  Direct my gift to the 'Gratitude Campaign' 
  Direct my gift to another specified area: 
  Tribute Name 
  First Name 
  Last Name 
  Address 2 
  Zip/Postal Code 

Contact Information
* Title (Mr/Ms) 
* First Name 
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  Company Name 
* Address 
* City 
* Province 
* Postal Code 
  Home Phone 
  Cell Phone 
  Work Phone 
* Email 

Credit Card Information
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  Expiration Date 
* Security Code  
Billing Address
  Same As Above 
* Address 
* Postal Code 

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Return Policy
If you have any questions or concerns with your payment, please contact us using the information provided in the Contact Us section.

Contact Us: Northern Lights Health Foundation •• Main Floor, 7 Hospital St. Fort McMurray, AB, T9H 1P2 •• 780.791.6041 •• foundation@nlhf.ca

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