benefactor donor ($400 - $599) at an annual gift of $______
patron donor ($600 - $999) at an annual gift of $______
visionary donor ($1000 - $2499) at an annual gift of $_____
deluxe donor ($2,500 and above) at an annual gift of $____
Yes, i want to become a donor!
$25
$50
$100
$250
Other Amount: $_________
Registered charity #871515995RR0001. We only issue tax receipts for donations of $25 or greater.
My info
name ____________________
additional member name (Associate or higher)
____________________
address _________________________
city ____________________
prov ___________ postal code ___________
Phone (day) ( ) _______________
Phone (eve.) ( ) _______________
email ____________________
I will pay by
VISA cheque (payable to: Inside Out)
total amount enclosed: $ ____________________
VISA number: ____________________
Expiry date (mm/yy):_______________
Signature:____________________
Please return to: Inside Out, 401 Richmond Street West, Suite 219, Toronto, ON M5V 3A8. If paying by VISA, you can fax this form to 416.977.8025
Please include me on your email list for year-round events!
Occasionally we exchange our mailing list with other non-profit organizations in the LGBTT community
Please do not exchange my name.
Do not publish my name in your program guide.