Secure Monthly Donor Signup

Please consider becoming a regular contributor.
This form makes it very easy to become a valued monthly donor. You can set the amount you would like to donate and provide a credit card from which you donation will be made each month. You will also receive a tax receipt at the beginning of the following year, just in time for tax season.

Personal Information
If you would like to receive a tax receipt for your donation, please provide all of the requested information.
Title [Mr.Mrs.Ms.Dr.]
First Name
Last Name
Mailing Address
Zip/Postal Code
Phone (Day)

Contribution Amount
Please select an amount you would like to contribute.
Contribution Amount:

Credit Card Information

Please type the card holder name as it appears on the credit card.  A tax receipt will be issued to the individual or compnay (for corporate gifts) named on the credit card.  In the case of a corporate gift, please include your company name as it appears on your company credit card.  Your credit card number should not include any spaces.

Cardholder Name:
Credit Card #:
Security Code (CVV2):
Card Type:

Additional Information
Please send us a message! We appreciate any feedback. Thank you!

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Mailing Address:

Halton Women’s Place
2211 Brant Street, #20060
Burlington, ON L7P 0A4