Name:       ______________________________________________

Address:  ______________________________________________
 
                 ______________________________________________
 
Phone:      ______________________________________________

Donation Amount: __________________

Payment Method:

    Cheque (enclosed): ___ payable to "The Rotary Centennial Playground"

    Credit Card => Visa: __  Mastercard: __  American Express: __

         * Card Number: __________________

         * Expiry Date: _______ (mmyy)


Please complete this form and mail it to:

Rotary Centennial Playground
c/o Susan Goddard
2 Bainbridge Ave.
Nepean ON  K2G 3S9
Canada