Donation Form

I would like to make a contribution of:

$25.00  $50.00  $100.00   $250.00 

Other amount $_________________

Cheque/Money Order payable to:

The Murphy Centre

95 Water St.

St. John’s, NL

A1C 1A5

Please send me more information on how I, or my company, can support the Murphy Centre.

Name _________________________________________________

Title ___________________________________________________

Company _______________________________________________

Address 1 ______________________________________________

Address 2 ______________________________________________

Telephone ______________________________________________

Fax ___________________________________________________

Email _________________________________________________