Date
Name and/or Organization
Address
City / Province / Postal Code
Phone / Fax
Email
Organization ($50.00) Individual ($20.00) I / We wish to volunteer. I / We wish to donate. Donation Amount:
Charitable Organization # BN887132793RR0001
Please return this form with cheque payable to: Ottawa Council on Smoking and Health 100 Constellation Crescent 7th Floor East Ottawa, Ontario K2G 6J8
