Run for Leucan 2019

Please donate now.

Thank you for your generous support.

Please provide your contact and payment information below. Your contact information is required to generate an electronic tax receipt which will be sent to the email address that you provide.

Please note that refunds will be handled on a case-by-case basis.

* denotes required information

Make a personal donation:
Make your donation on behalf of an organization or company:

* Title:
* First Name:
* Last Name:

* Organization:

Contact Information


	Home Work

Enter address manually
* Address (Ex.: 550, Beaumont Ave, Suite 300):

* City/Town:
* Country:
* * * Province/State:
* Postal/Zip Code:
Phone Number:	( ) Ext.
Cell Phone Number:	( )
* Email Address:


I give Leucan permission to contact me by mail (post).

Tell us a bit about yourself.

When is your birthday? (Used for statistical purposes only. Leucan will never disclose your personal information.)

Payment Information

Pay using Credit Card
Card Security Number is not supported in data entry. To process a credit card payment, you need to disable Card Security from the Electronic Payment page in the Configuration tab.
Payment Method:	One Time Payment Credit Card
* * Donation Amount:	$30 $50 $100 $250 Other
* Processing Date:
	installments
Pay using PayPal
* Credit Card Type:
* Credit Card Number:
* Card Security Number:	Where is my Card Security Number?
* Cardholder's Name:
* Credit Card Expiration:
Card Valid From
Issue Number
* Bank Name:
* Bank ID:
* Cheque Number:
* Transit number:
* Account Number: