Donation Form

To make a donation, please complete the form below.
Your support is integral to the success of our fundraising event. 
If you are interested in becoming a Sponsor, please click here for more information.

* Indicates required field

Name *

First

Last

Company Name *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Donation Type *

Monetary (Please complete payment information below) Prize/In-kind (Please complete details below)

Phone Number *

Monetary Donation Amount *

Prize/In-kind Description (Please include description and approximate value) *

Select Method of Payment *

Company Cheque (Payable to: Reliance Products Ltd. Mail to: Reliance Products 1093 Sherwin Rd, Winnipeg, MB R3H 1A4 Credit Card (Enter Info below)

Name on Credit Card *

Do you require pick-up of your gift donation? If so, please include pick-up location, contact name and phone number below. *

Amount in ($) Dollars *

Card Type *

Credit Card Number *

Expiry Date *

CVC # *

Receipt Required for Cash Donation? *

Submit

Donations

Donation Form