Yes! I wish to make a donation and receive The Puzzle of Perimenopause video.
| Name |
_____________________________________ |
| Address |
_____________________________________
|
| City/Town | _____________________________________ |
| Province/State | ____________ |
| Postal/Zip Code | ____________ |
| Telephone No. | ( ) ___________________ |
| Fax No. | ( ) ___________________ |
| E-Mail Address | _____________________________________ |
| Please send me __________ Videos. | |
I enclose a donation (cheque, money order, or credit card) in the amount of $35 Cdn ($25 US) for (PAL Version = 25 Euro) EACH video, payable to the:
BC Endocrine Research Foundation
281-828 West 10th Avenue
Vancouver BC V5Z 1L8
Payment Method:
Cheque
Money Order
Visa
MasterCard
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| Expiry Date | _______________________________ |
| Name shown on card | _______________________________ |
| Signature | _______________________________ |
Yes. Please send me a tax receipt for my donation (Minus costs for video production, shipping and handling).

