CORPORATE CONTRIBUTION Pauline Raymond-Martimbeau Educational Grant

Educational Grant to "Dr. Pauline-Raymond Martimbeau Educational Grant"
(enter amount)
Company Name*
Contact Name
First name*
Last name*
Title*
Business Address
Address*
Street Suite City Province / State / Region Postal code / ZIP Country
Phone (office)
Cell.
Phone/cell. (international)
Email*
Summary
Category

Educational Grant
Total amount
$ 0.00 CAD
Payment
Payment method*
- Credit card
- Cheque
Credit card*

Card Details

Cardholder Name
Make the cheque payable to «Canadian Society of Phlebology» and send it to the mailing address listed below.
Do not forget to include with your payment a copy of the confirmation form that you will receive by email.
Canadian Society of Phlebology
5-302 Rang des Vingt
Saint-Basile-le-Grand, QC
J3N 0E8
Tribute to Dr. Pauline Raymond-Martimbeau (optional)
If clicking SUBMIT takes you back to the top of the page, please complete the required fields and SUBMIT again until you get the confirmation page.
Comments
This field is for validation purposes and should be left unchanged.

Contact Name