1Confirmation2Ticket Purchase3Donation4Contact and Billing5Payment Method6Credit Payment7Cheque Payment Thank you for supporting our fundraising event. We are grateful for your donation to attend our upcoming Leader's Dinner fundraising banquet on Friday, October 28, in Moncton. Please RSVP by Thursday, October 27th. Will you be attending this event?* Yes, I would like to purchase a ticket I can't attend the event but I would like to support it with a donation I would like to donate this amount per seat*$200 per seat$375 per seat$490 per seat$750 per seat$1000 per seatQuantity*Maximum yearly contribution is $3000 per individual. Total $ 0.00 CAD Please indicate any dietary restrictions you and/or your guests may have (if applicable) Vegan Vegetarian Gluten Free No pork products Nut allergy Seafood / Shellfish allergy The venue will do its best to accommodate any dietary needs that your or your guest(s) may have.Your guest list (if applicable)For multiple RSVPs to this reception, please indicate your guest(s) here. Indicate which guests have dietary restrictions (if applicable.) I won't be attending but I would like to support the following event:2022 Leader's Dinner - DONATIONCan't join us? Show support by making a general contribution to the event. Your donation may be eligible for a tax credit.Please note: corporations, businesses and trade unions cannot make political contributions in New Brunswick as of June 1st, 2017. Please ensure that all donations, ticket purchases, and convention fees are made on behalf of an individual using only a personal credit card and/or personal cheque.Frequency* Monthly One-Time Donation $5 $10 $50 $100 $250 Other Other Amount Total $ 0.00 CAD Please note: corporations, businesses and trade unions cannot make political contributions in New Brunswick as of June 1st, 2017. Please ensure that all donations, ticket purchases, and convention fees are made on behalf of an individual using only a personal credit card and/or personal cheque. Name* First Last Phone*Email* Billing Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code I would like to give my donation to…--New Brunswick Liberal AssociationRestigouche WestCampbellton-DalhousieRestigouche-ChaleurBathurst West-BeresfordBathurst East-Nepisiguit-Saint-IsidoreCaraquetShippagan-Lamèque-MiscouTracadie-SheilaMiramichi Bay-NeguacMiramichiSouthwest Miramichi-Bay du VinKent NorthKent SouthShediac Bay-DieppeShediac-Beaubassin-Cap-PeléMemramcook-TantramarDieppeMoncton EastMoncton CentreMoncton SouthMoncton NorthwestMoncton SouthwestRiverviewAlbertGagetown-PetitcodiacSussex-Fundy-St. MartinsHamptonQuispamsisRothesaySaint John EastPortland-SimondsSaint John HarbourSaint John LancasterKings CentreFundy-The Isles-Saint John WestSaint CroixOromocto-Lincoln-FrederictonFredericton-Grand LakeNew Maryland-SunburyFredericton SouthFredericton NorthFredericton-YorkFredericton West-HanwellCarleton-YorkCarletonCarleton-VictoriaVictoria-La ValléeEdmundston-Madawaska CentreMadawaska Les Lacs-EdmundstonYou may direct your donation to a specific provincial riding or to the NBLA central fund. Type of payment* Personal Credit Card Personal Cheque Personal Contribution* I am making this donation with personal NOT business/corporate/trade union funds. No entity will reimburse me. This donation amount may be eligible for a provincial tax credit. Your registration address must match the billing address for the credit card submitted below. If fraud alert message is displayed, please note your submission has been received and will be reviewed by our office. You do not need to complete the form again. Total Amount: $ 0.00 CAD Credit Card American ExpressMasterCardVisaSupported Credit Cards: American Express, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name There is a short delay for processing after clicking the “Submit” button. Please click the button once and wait for the Thank You page to appear. Please deliver your cheque as soon as possible to: New Brunswick Liberal Association 715 Brunswick Street Fredericton, NB, E3B 1H8HiddenDo you acknowledge that payment must be received by the NBLA prior to the event? I understand. Total Amount: $ 0.00 CAD There is a short delay for processing after clicking the “Submit” button. Please click the button once and wait for the Thank You page to appear.
New Brunswick Liberal Association
715 Brunswick Street
Fredericton, NB, E3B 1H8