DOMINO THEATRE FUNDRAISING CAMPAIGN 2010- 2011 DONATION FORM NAME: . ADDRESS: . PHONE # . E-MAIL . I am pleased to donate/pledge the following total amount to Domino Theatres fundraising: $ .. To: Domino Theatre Inc: Box 884, Kingston K7L 4X8 This donation/pledge to be paid as follows: $ ..now And the following amounts in each of the following years: $ . In 2011 $ ..in 2012, $ in 2013, $ ..in 2014 and $ .in 2015 IF PAYING BY CREDIT CARD Please note credit card type Credit Card Number Expiry Date Signed: Date: For Domino ..