AETHEROMETRY SPONSORSHIP FORM

 

Please print this order form, fill it out, and enclose it with your bank draft or money order, so that we can properly direct and acknowledge your contribution.

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Make out your bank draft or money order to:
Paulo and Alexandra Correa.
Send it to:
Aurora Biophysics Research Institute
7777 Keele Street, Unit 8, Box 79118
Concord, Ontario L4K 1Y7, Canada

Amount of Contribution ____________________________   

Name of Contributor __________________________________________________

Street or PO Box: __________________________________________________________________

City: _____________________________________________________

State or Province: ____________________________ Zip or Postal Code:____________________

Country: _____________________________________________________

Telephone: Day ____________________________ Night _________________________

Email: _____________________________________________________


Additional Directives or Comments: