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| Print Name: |
_______________________________________ |
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| Address: |
_______________________________________ |
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| Town/City: |
__________________________, Alberta |
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| Postal Code: |
_____________ Email: ____________________ |
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| Phone: |
| ( ) _________________ |
Fax: |
( ) ________________ |
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Membership: |
$10.00 |
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Donation Amount: |
$_________________
Please review the Contribution list
below |
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Total Amount: |
$_________________
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If paying by cheque, Cheque #:________ Date: __________ |
| Or |
| Select Card Type: |
___ Visa ___ Mastercard |
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| Card Number: |
__________________________________ |
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| Expiry: |
_________ |
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Name as appears
on Card: |
_______________________________ |
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Card Holder's
Phone Number: |
_______________________ |
I want to volunteer in the area(s) circled here:
Constituency
Administration Campaigning
Fundraising Other: _______________________________
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| Contribution | Tax Credit | Actual
Cost | |
| $150.00 | $112.50 |
$37.50 | |
| $500.00 | $300.00 |
$200.00 | |
| $1,000.00 | $550.00 |
$450.00 | |
| $1,500.00 | $733.32 |
$766.68 | |
| $2,000.00 | $900.00 |
$1,100.00 | |
| $2,300.00 | $1,000.00 |
$1,300.00 | Your MAXIMUM tax benefit |
| $5,000.00 | $1,000.00 |
$4,000.00 | |
| $10,00.00 | $1,000.00 |
$9,000.00 | |
| $15,000.00 | $1,000.00 |
$14,000.00 | Your ANNUAL maximum to the Party |
| $30,000.00 | $1,000.00 |
$29,000.00 | Your Maximum to the Party
during a Campaign Period |
| Please note any contributions
over $375 are made public by the Chief Electoral Officer of Alberta |
| By completing this form, you consent to its collection and use
by the Separation Party of Alberta, to process your request. Your information is subject to strict privacy rules
as summarized on www.separationalberta.com and is not sold or traded or otherwise used for commercial purposes.
If you wish to revoke or change your consent, contact the Privacy Officer in writing at the above address, including
your full name and contact information. Such requests are subject to legal restrictions. |
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