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):*
Date Format: MM slash DD slash YYYY
Ending Date (mm/dd/yyyy):
Date Format: MM slash DD slash 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:
- Yes
(Please allow for 10 days to process your request)
I wish to subscribe to The AFC mailing list.
- Yes