HCI Digital Donation Form for Completed Donations Form 2

Human Concern International - Edmonton Region

Thousands of people depend on aid to survive and need your support - Donate Now
Please fill out the form below for completed donations only

Donor's Information
Name*

First NameLast Name
Organization Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.

Type a question
Your HCI Program*
Your HCI Program beneficiary*
Comments
Kindly share any additional information here if you wish to make specific requests related to your donation
How many children would you like to sponsor?*
$60 per month for one child

$360 for half a year for one child

$720 for one year for one child
How long would you like to sponsor?*
Please specify the number of months
Gift Amount - Please choose your donation amount*
Gift Amount - Please enter your donation amount*
Payment Method - Pay now by:*

CashCardCheque
Please enter last 4 digit of the credit card*
Please enter the HCI representative code*
I acknowledge that the deposit slip is pending for this donation*
Please enter your full name above to acknowledge
Please upload a file for any donation related information

Please upload a file for any information related to donation (such as copy of a cheque or donor credit card receipt etc)
Cancelof
Donation Date*

MonthDayYear
MM-DD-YYYY
By signing this form, I confirm that the information provided above is true and correct.
Signature

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info@humanconcern.org l 1-800-587-6424 l humanconcern.org
Charitable Registration No. 107497125 RR 0001
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Human Concern International - Edmonton Region