Donation Form

 First Name:*  
 Middle Name:  
 Last Name:*  
 Telephone Res: ( ) -  
 Telephone Other: ( ) - ext.
 Email:*
 Unit/Street No.:*
 Street Address:*
 City:*  
 Postal Code:*
 Amount(CAD):* Donations must be made from Canadian bank accounts, and Legal Residents of Canada only.
 Remark:
Please make cheque payable to Michael Chan, CGA; Official Agent
Memo: Chungsen Leung Campaign
Mail to: 106, 350 Hwy 7 East, Richmond Hill. ON L4B 3N2