Candidate Contribution Rebate Application

Donations of less than $50 are not eligible for a rebate.

Receipt Number:

Date of Contribution:

Date Receipt Issued:

Amount Received (Donation Amount):

Form of Contribution:

Cash (not exceeding $25.00)/Cheque/Money Order

Credit Card

Received From:

Resident in Ontario

I wish to apply for a rebate

Contributor Information:

First Name:

Last Name:

Address:

City/Town:

Province:

Postal Code:

Candidate for the Office of:

Candidate Name:

Signature:

Clear