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Fillable Form
Aisha Mosque
235 rue Peel, Montréal, QC H3C 2G6, Canada
Please fill out the information below, and return to the Aisha Mosque.
Donor Information
Last Name
First Name
Address
City
Province
Zip Code
Country
Email Address
Phone Number
(day)
Evening
Signature
Payment Option
Monthly pre-authorized withdraw from your bank account (please provide a copy of your
sample cheque mark “void” (a photo copy is also acceptable))
Pre-authorized withdrawals will be stopped upon notification
PayPal (email required)
Credit card -
American Express
MasterCard
VISA
Number:
Expiration Date:
(mm/yyyy)
Post dated cheque
Cheques should be made payable to: "Darus Salam"*
Other:
(Specify)
Specify your financial commitment
$
Monthly
Annually
Other
Date of Start:
For an aggregate contribution of $100 or more annually, an official receipt for Canadian income tax
purposes will be issue by Mosquée Darus Salam (an umbrella organization) before March 1 of each year.
* Mosquée Darus Salam, a Canadian Registered Charity # 875103616RR0001