Brazil Donation Form - St. Baldrick`s Foundation

Brazil Donation Form
StBaldricks.org
Questions? Please call
Toll Free in U.S.: 1.888.889.2253
Brazil: 55 (21) 4002 2508
Participant Name
ID#
Event Year
Team
Site
Please return this form to the participant you are sponsoring.
Donation
Donation
To donate by credit card in Brazilian reais or U.S. dollars please visit the Brazilian event, team or participant webpage
at StBaldricks.org.
Please select a payment method below:
Give in Brazilian Reais
Give in U.S. Dollars
To give via an identified deposit please deposit your
donation, through DOC, into the bank account below:
Make checks payable in U.S. funds to St. Baldrick’s
Foundation. Please include the Participant Name and ID#
in the memo section of the check.
Bank Information
Bank: Banco do Brasil
Agency Number: 2234-9
Account Number: 204783-7
CNPJ: 40.226.946/0001-95
 $1,000
 $750  $500
 $250  $100
To make an international wire transfer to the St. Baldrick’s
Foundation please call 888 899 2253 or email
[email protected].
*These gifts are tax deductible in the U.S.
 $1,000
 $750  $500
 $250  $100
 Other (specify) $______________
 Other (specify) $______________
 YES! I’d like to receive more information about
Fundação do Câncer.
 My employee matching gift form is enclosed.
Employer Name
Donor Information
Name (Contact person, if business donation)
Company (only if donation is from a company)
Address Line 1
Address Line 2
City
Country/U.S. State
Day Phone
E-mail Address
Postal/Zip Code
Fundação do Câncer, Rua dos Inválidos, 212, 8º andar, Centro, Rio de Janeiro, Brasil
www.cancer.org.br
St. Baldrick’s Foundation, 1333 S. Mayflower Avenue, Suite 400, Monrovia, CA 91016, USA
Federal Non-profit ID#20-1173824