Bequest Acknowledgement

Title TitleMr.Mrs.Ms.Miss.Dr.Mr. & Mrs.

Full Name

Email Address

Phone Number

Street Address

Province ProvinceBritish ColumbiaAlbertaSaskatchewanManitobaOntarioQuebecNew BrunswickNova ScotiaPrince Edward IslandNewfoundland and LabadorYukonNorthwest TerritoriesOutside Canada

Country CountryCanadaOther

Postal Code

Tell us about your connection to the Terry Fox Humanitarian Award Program

Date of Birth

Spouse's Date of Birth (if applicable)

Planned gift(s) to the Program Planned gift(s) to the Program Including the Terry Fox Humanitarian Award Program in my Will Gifts of Stocks and/or Securities Gifts of Life Insurance Personal Endowment Funds Retirement Funds - RRSPs or RRIFs Donor Advised Funds Stock Options

I wish to remain anonymous in terms of public recognition I wish to remain anonymous in terms of public recognition Yes No