Yes, I would like to become a member of St. Stephen's Community House Opportunity Fund by making a monthly contribution of:

$ _______________ by

     Cheque (enclose cheque marked "void")
     VISA
     MasterCard

Cardholder's Name: _________________________   Signature: ____________________

Card Number: __________________________________   Expiry Date: ______________

Address: _________________________________________________________________

_________________________________________________________________________

City/Town: ______________________   Province: ____   Postal Code: ______________

Home Phone: ( ___ ) - ________________   Work Phone: ( ___ ) - _________________

Email Address: ____________________________________________________________

Please fill out this form and mail or fax it with your monthly pledge to:

St. Stephen's Community House
91 Bellevue Avenue
Toronto, ON  M5T 2N8
Fax: 416-925-2271

St. Stephen's Community House is a registered charity.
Our Canadian Charitable Registration Number is 11920 1960 RR0001.