End Polio Now Pledge


Donations of $20 or over will be eligible for a charitable receipt.

Please complete all entries.

First Name: 
 
Last Name: 
 
Address: 
 
City: 
 
Province: 
 
Postal Code: 
 
Email: 
 
Phone: 
 
Enter whole dollar amounts without adding .00.

PLEDGE Amount $: 
 



Personal information is strictly confidential and will not be disclosed to any third parties or used in any other way except
to confirm your pledge and for a charitable donation receipt.