FSMA Logo

Families of 
Spinal Muscular Atrophy Canada
 Pledge Form

I want to make a donation 
to help cure SMA in the amount of  $_________________
(Please print and mail this form 
to the address below)
This donation is   (complete one if desired)
In Honor of:

_________________________________________________
In Memory of:

_________________________________________________
For Occasion:  _________________________________________________

Name / Company Name: _____________________________________________

Address:__________________________________________________________

_________________________________________________________________

City: ______________________ Prov:_________ Postal Code:_______________ 

Phone: (_______)____________________

Method of 
Payment

 [ n/a  ] Charge to my credit card (please complete information below)
[   ] Cheque enclosed 

(we are not yet able to process credit card payments - please send a cheque)

Amount:

Cdn$ ___________

[  n/a ] Visa     [  n/a ] MasterCard

Card no.:

___________________________________

Expiry date:

_____/_______

Name on card:

______________________________________________

Signature:

______________________________________________

THANK YOU VERY MUCH!!!
Please make cheques payable to FSMAC and mail to:
Families of SMA Canada 
P.O. Box 97
Rivers, Man. R0K 1X0
800-866-0016
Fax: (204) 328-7803
www.CureSMA.ca


(All donations are tax deductible)