PATRON'S MEDAL ORDER FORM

I wish to support the aims and objectives of the Canadian Lifeboat Institution by joining the distinguished ranks of its patrons. I understand that I will receive a medal and certificate with my tax deductible contribution.

	Gold medal (minimum $1000)	____________________

	Silver medal (minimum $500)	____________________

	Bronze medal (minimum $250)	____________________

	Miniatures ($40)		____________________

			subtotal	____________________

	GST & PST (if applicable)	____________________

			TOTAL		____________________

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Please indicate method of payment

CHEQUE____ VISA____ MASTERCARD____ OTHER____

(*** DO NOT SEND CASH THROUGH THE MAIL ***)

Card Number: ________________________________________

Expiry Date: ________________________________________

Signature: __________________________________________

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I understand that I can designate how my contribution will be used.

  $ __________ for capital purchases (lifeboats, stations and equipment)

  $ __________ for operational costs (fuel, training, etc.)

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Name: _______________________________________________

Address: ____________________________________________

City: _______________________________________________

Province: ___________________________________________

Postal Code: ________________________________________

Home Phone: _________________________________________

Work Phone: _________________________________________

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MAILING ADDRESS:	CANADIAN LIFEBOAT INSTITUTION,

			401 EAST WATERFRONT ROAD,

			VANCOUVER, B.C.

			V6A 4G9

A tax receipt will be provided for all donations of $25.00 or more.