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10247 - 124 Street NW Edmonton, Alberta T5N 1P8

DONATION FORM

Name and Contact Information

Phone: 1-800-661-9201 Fax: 780-414-1125 Web: www.albertaliberal.com

DONATION TYPE (CIRCLE ONE)

NAME

/

CORPORATE ADDRESS

INDIVIDUAL

UNIT NO.

MUNICIPALITY

POSTAL CODE

CONTACT PHONE

-

-

EMAIL

Donation Amount Get up to 75% of your donation back! See below!

Payment Information

  Yes! I/we would like to make the following donations:

$

/month

$

/month

AND/OR

$

/one time

To the Alberta Liberal Party, using the payment information provided below.

AND/OR

$

/one time

To the Provincial Liberal Association, using the payment information provided below.

CHEQUE (Payable To: Alberta Liberal Party) If joining a monthly contribution plan, please attach a blank cheque marked VOID. By attaching a voided cheque you hereby authorize, direct, and request your financial institution to debit the account attached to your cheque by the amount(s) stated above on the first of each month, and deal with each cheque as if it were signed by you personally.

CREDIT CARD NUMBER

EXPIRES

/

 NAME ON CARD

Donation Information

GET BACK

75%

OF YOUR FIRST $200 DONATED

SIGNATURE

GET BACK

GET BACK

50%

33%

OF YOUR NEXT $900 DONATED

OF YOUR NEXT $1200 DONATED

ACTUAL COST

$25 OF A $100 DONATION

Contributions to the Alberta Liberal Party qualify for tax credits which directly reduce your Alberta Tax Payable. Contributions are subject to the limits laid out in the Election Finances and Contributions Disclosure Act. Only eligible contributors may donate to the Alberta Liberal Party. An eligible contributor is defined as: a resident of Alberta, a corporation registered to carry on business in Alberta, or a trade union/employee organization.

Affirmation

 I certify that I am/we are eligible to contribute to the Alberta Liberal Party under the Election Finances and Contributions Disclosure Act, and that this money was not given to me/us by a third party for the purposes of making a contribution.

DATE

x

SIGNATURE

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