Victoria Medical Heritage Society Donation Form One-Time Donation of:  $ _______________ Pledge of:  $_______________  for  2 months  ___    4 months  ___   6 months  ___ Cheques and Money Orders: Please make payable to:  "The Victoria Medical Heritage Society". Credit Card: VISA  ___   MasterCard  ___American Express  ___   Credit Card Number:  __________________________ Expiry Date:  month [        ]  year [        ] Signature:  __________________________________ Name:  (please print)  __________________________________ Address:  (please print) Apt. #  ______ Street __________________________________ City ________________________ Postal Code  ____________ Telephone:  home  __________________   business  __________________ Special instructions - i.e.  in memory of, acknowledgement to whom, etc. (Use the back of this form if you require more space) ___________________________________________________________________________ Please print this form, complete it and send it to: Victoria Medical Heritage Society 190 -2334 Trent Street Victoria, BC Canada V8R 4Z3 Thank you for your support! The Victoria Medical Society <<  return to Home Page