Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.315 Front Street W, 5th Floor Toronto, ON M7A 0B8 Telephone: 437-925-6227 federatedhealth.caNAME AND ADDRESSAgency *Division (name or number) *Name *FirstLastToday's date *City *Province *Postal Code *Phone (office) *Email *CONTRIBUTION AND PAYMENT DETAILSPayroll deductions *I AUTHORIZE PAYROLL DEDUCTIONS:Time limited deduction or ongoing deduction *Time limited deductionOngoing deductionDeduction per pay (time limited) *Deduction per pay (ongoing deduction) *Pledge renewal enrollment *AUTOMATIC PLEDGE RENEWAL ENROLLMENT: I agree to have my payroll deduction as described above, automatically renew on an ongoing basis.Amount of pays *Maximum 26Total to be deducted *Employee # *Signature *Please type your name.I WISH MY DONATION TO GO TO: *ALL 21 HEALTH CHARITIES (Vendor #200)THE CHARITIES I HAVE CHOSENCanadian Cancer SocietyCanadian Cancer Society (Vendor #203)Donation to Canadian Cancer Society (Vendor #203)Heart & StrokeHeart & Stroke (Vendor #204)Donation to Heart & Stroke (Vendor #204)Diabetes CanadaDiabetes Canada (CDA/JDFC) (Vendor #205)Donation to Diabetes Canada (CDA/JDFC) (Vendor #205)Hemophilia OntarioHemophilia Ontario (Vendor #206)Donation to Hemophilia Ontario (Vendor #206)Spinal Cord Injury OntarioSpinal Cord Injury Ontario (Vendor #207)Donation to Spinal Cord Injury Ontario (Vendor #207)The Kidney Foundation of CanadaThe Kidney Foundation of Canada (Vendor #208)Donation to The Kidney Foundation of Canada (Vendor #208)Lung Health FoundationLung Health Foundation (Vendor #209)Donation to Lung Health Foundation (Vendor #209)Alzheimer Society of OntarioAlzheimer Society of Ontario (Vendor #210)Donation to Alzheimer Society of Ontario (Vendor #210)The Arthritis Society – Ontario DivisionThe Arthritis Society – Ontario Division (Vendor #211)Donation to The Arthritis Society – Ontario Division (Vendor #211)Crohn’s and Colitis CanadaCrohn’s and Colitis Canada (Vendor #212)Donation to Crohn’s and Colitis Canada (Vendor #212)Ontario Federation for Cerebral PalsyOntario Federation for Cerebral Palsy (Vendor #213)Donation to Ontario Federation for Cerebral Palsy (Vendor #213)Cystic Fibrosis CanadaCystic Fibrosis Canada (Vendor #214)Donation to Cystic Fibrosis Canada (Vendor #214)Canadian Liver FoundationCanadian Liver Foundation (Vendor #215)Donation to Canadian Liver Foundation (Vendor #215)Ontario AIDS NetworkOntario AIDS Network (Vendor #216)Donation to Ontario AIDS Network (Vendor #216)Osteoporosis CanadaOsteoporosis Canada (Vendor #217)Donation to Osteoporosis Canada (Vendor #217)Institute for Advancements in Mental HealthInstitute for Advancements in Mental Health (Vendor #218)Donation to Institute for Advancements in Mental Health (Vendor #218)ALS Society of CanadaALS Society of Canada (Vendor #219)ALS Society of Canada (Vendor #219)MS Society of CanadaMS Society of Canada (Vendor #220)MS Society of Canada (Vendor #220)Parkinson CanadaParkinson Canada (Vendor #221)Parkinson Canada (Vendor #221)Autism OntarioAutism Ontario (Vendor #222)Autism Ontario (Vendor #222)Sickle Cell Awareness Group of OntarioSickle Cell Awareness Group of Ontario (Vendor #223)Sickle Cell Awareness Group of Ontario (Vendor #223)DONATE TO CELEBRATE OR REMEMBERType of dedication (optional)In memory ofIn honour ofNoneThe name of the person you dedicate this donation to: *Do you want us to notify anyone of this donation? *YesNoPlease provide us with the name of the person you want us to notify of this donation. *Do you want us to send *a hard copy cardan e-cardPlease provide us with the mailing address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPlease provide us with the email of the person you want us to notify of this donation. *PRIVACY & TAX RECEIPTSLayout• Tax receipts will be issued for gifts of $25 and over.• Gifts made by payroll deduction are recorded for income tax credit on box 46 of your T4 slip.Privacy: Individual donor information is maintained in order to issue income tax credit under the regulations of the Canada Revenue Agency. This information is maintained in a strictly confidential manner and is never traded, rented, sold or otherwise revealed to any organization in whole or in part — including the charities that benefit from the campaign.CHARITABLE REGISTRATION NO. 85413 5480 RR0001 FEDERATED HEALTH CHARITIES CORPORATION Custom Captcha * = NextUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.Go backConfirm & Submit