Firefighters Burn Fund Victoria, BC

www.firefightersburnfundvictoria.ca, or ...email

Printable Direct Donor Form

Please send my receipt to:
Name	________________________________
Street Address	________________________________
City	________________________________
Province	________________________________
Postal Code	________________________________
I wish to make a cash donation of:	________________________________
Information Request
I would like more information on the following: [   ] Survivor Support [   ] The Burn House [   ] Youth Fire Setter Intervention [   ] LNTB Program [   ] Other   _________________________________________________ Phone Number (Including area code) __________________________________________________________ Best Time to Reach Me: __________________________________________________________

Thank You! Please print and fill out this form. Mail it with your cheque or money order to:

Firefighters Burn Fund Victoria, BC
2504 Richmond Road
Victoria, BC
Canada
V8R 4S4

Or fax to:
(250) 370-1272

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