CHHA
   
 

CHHA Online Donation Form

Please complete the following form and click "Submit" at the bottom of the page. All fields marked with "*" are mandatory.

Contact Information

First Name*:

Last Name*:

Address*:
City*:
Province/State*:
Postal/Zip Code*:

Country*:

Canada
United States
Phone Number*:
Mobile Number:
Fax Number:
E-Mail*:
Is this a Monthly Donation (yes or no)?:

Donation Information

Donation

$25 Donation
$50 Donation
$75 Donation
$100 Donation
Other (minimum $10 please)

Payment Information

Credit Card

By paying by credit card, I understand that my credit card statement will show this transaction as "C.H.H.A" and I will ensure that anyone who reviews the statement is aware of the transaction.

Name on Credit Card:
Card Type:
Credit Card Number:
CVV Number:
Expiration Date: MM/ YY
Please provide billing address
Street number:
Street name:
Zip/Postal code:

Cheque

Please make your cheque payable to the "CHHA" and mail to:

Canadian Hard of Hearing Association
2415 Holly Lane, Suite 205
Ottawa, ON K1V 7P2

Questions?

If you have any questions about your donation, please contact Karla Wilson by phone at 800-263-8068.