Chabad of Regina Donate Form

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Donor E-Mail
Important: Enter a valid e-mail address. Receipts will be sent to this address.
E-Mail:*
Donation Information
Donation Type:*	Single Gift Monthly Gift Annual Gift
Gift Amount*	$1800.00 $1000.00 $540.00 $360.00 $180.00 $100.00 $54.00 Other
Gift Amount:*		Amount of donation
Purpose*		Choose your fund
Billing Information
First Name:*
Middle Initial:
Last Name:*
Address Line 1:*		Where your statement is mailed
Address Line 2:		Apt. or Suite No.
City:*
Province/State*
Postal/Zip Code*
Phone:*
Credit Card Information
Card Number:*		No dashes or spaces please
Secure Code:*		3 or 4 digit security code
Expiration Month:*		From your card
Expiration Year:*		From your card
Credit Card/Banking Information
Method of Payment*	Credit Card Automated Account Debit
Card Number:*		No dashes or spaces please
Secure Code:*		3 or 4 digit security code
Expiration Month:*		From your card
Expiration Year:*		From your card
Card Brand:*
Transit Number*
Financial Institution Number*
Account Number*
Additional Notes/Comments
Notes
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