_________________________________________________________________________________________________
First name Last name
_________________________________________________________________________________________________
Address City Province Postal code
_________________________________________________________________________________________________
Email address (Your tax receipt will be sent to this address) Phone
I prefer a paper tax receipt For all recognition purposes, I/we wish to remain anonymous
YES! I WILL TAKE MY PLACE!
I would like to make a gift of $ _______________________
Please direct my gift to:
Indigenous Success Fund Graduate Student Scholarship Fund
Undergraduate Scholarships Undergraduate Bursaries
I would like to support students in
any eld of study or in the Faculty/College of ______________________
or
I would like to support
Research Excellence Fund Experiential Education Fund Enriching Places and Spaces
Upgrades to libraries, classrooms and labora
tories Active Living Centre
Taché Arts Project Other _____________________
PAYMENT METHOD
Payroll deduction
Sta number
__________________________________
I am paid: Bi-weekly Semi-monthly
Beginning on _____ / _____ / _____ (d/m/y)
Until _____ / _____ / _____ (d/m/y) or ongoing
Signature
_____________________________________
Charitable donations made via payroll deduction will appear
on your T4 Summary from the U of M.
Credit card
Visa Mastercard American Express
Card number
__________________________________
Expiry date _______ / _______
Cardholder name
_______________________________
One-time Monthly Quarterly Annually
Beginning on _____ / _____ / _____ (d/m/y)
Cheque
made payable to the University of Manitoba
and mailed to the address below
FURTHER INFORMATION
An ocial tax receipt will be issued under Revenue Canada Taxation Registration #11976-0669-RR0001. Monthly donors will receive one receipt at year
end for all monthly gifts. This personal information is being collected under the University of Manitoba Act and will be used to facilitate communication
and assist in our advancement eorts. It will be used only for the purpose(s) for which it is collected, unless you consent or we are authorized to do so
under the Freedom of Information and Protection Privacy Act (FIPPA). For more information, contact the Access and Privacy oce at 204 474 9462.
Please return completed form to:
University of Manitoba, Alumni and Donor Relations
200-137 Innovation Drive
Winnipeg, Manitoba R3T 6B6 Canada
For more information, contact:
Jennifer Triggs in Alumni and Donor Relations
Phone: 204 474 7120
umanitoba.ca/giving/fsr
donor.relations@umanitoba.ca
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