CAPM&R Pledge Form

Canadian Association of Physical Medicine & Rehabilitation

Disclaimer

Please fill in the following form, print it on your own printer, sign it and send it along with your donation by mail or fax.

Canadian Physiatrists Research and Development Foundation

DONATION

Purpose of the Canadian Physiatrists Research and Development Foundation:
To promote research and development of the specialty by physicians in the field of physical medicine and rehabilitation.

Donation to the Canadian Physiatrists Research and Development Foundation:

Lump sum donation of:	$
Five year pledge of:	$

(yearly donation of this amount pledged for five consecutive years)

Yearly donation to be charged to the credit card listed below for five years

Payment method:

I have enclosed a cheque payable to the Canadian Physiatrists Research and Development Foundation

Visa Mastercard

Account No:

Expiration Date:

Name:

Signature:

Send my receipt to:

(Please print)

CPRDF
774 Echo Dr
Ottawa, ON K1S 5N8
Telephone (613) 730-6245
Toll free: 1-800-668-3740 ext. 245
Fax: (613) 730-1116
E-mail: capmr@rcpsc.edu

A charitable donation receipt will be issued for donations

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