Request Form

Your Name:*

First Last

(Must be your legal first and last name)

Your e-mail:*

Enter Email Confirm Email

Area Code / Phone:*

i.e (###)### - ####

Mailing Address:*

Street Address City Province Postal Code

Social Insurance #:*

i.e ###-###-###

I authorize The AFC to deduct donations from any paycheques issued by participating payroll companies by the following percentage:*

Starting Date (mm/dd/yyyy):*

Ending Date (mm/dd/yyyy):

(Your final pre-authorized donation will be processed on this date)

Please stop my donations when they reach:

OR - I will advise The AFC in writing when to stop:

(Please allow for 10 days to process your request)

I wish to subscribe to The AFC mailing list.