TRIPLE YOUR GIFT

Today, your donation is worth TRIPLE thanks to the Cole Foundation!*

*Up to $40,000.

Amount

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Did you know that by adding the amount of the transaction fees to your donation, you help Leucan support families even more?

Yes, I would like to add the transaction fees to my donation ( %ProcessingFee% ).

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Information

Name

Title Please select a Title

First First name is missing

Last

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Organization Name

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Contact

Enter address manually

Adresse 1 Address is missing

Country

State/Province Please select a Province

State Please select a State

State/Province State/Province is missing

City City is missing

Postal Code Postal Code is missing Postal Code is invalid

Telephone (Optional) Phone number is invalid. Please ensure you remove any special characters.

Email Address Email address is missing Email Address format is invalid

Payment

Name Credit Card Holder's Name is missing

Card # Credit Card Number is missing The credit card number must be 16 digits, optionally separated into 4 groups of 4 with blanks or dashes

Exp MM Please select the Credit Card Expiry Month

Expiry YY Please select the Credit Card Expiry Year

CVV (?) Credit Card Security Verification Number is missing The credit card security number must be between 3 and 4 digits The credit card security number must be 4 digits

Valid from MM

Valid from YY Credit Card Valid Fom Date is incorrect - both Valid From Month and Valid From Year must be selected or none selected

Issue Number Credit Card Issue Number can be a 2 digit number or blank

Bank Name Bank Name is missing

Bank ID Bank ID is missing The Bank ID must be 3 digits

Cheque Number Cheque Number is missing The Cheque Number must be 3 digits

Transit Number Transit Number is missing The Transit Number must be 5 digits

Account Number Account Number is missing

By continuing, you acknowledge that your credit card will be charged on a recurring basis for the duration outlined or until cancelled.