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Pay the Gift Card Way for Grand River Hospital
Pay the Gift Card Way for JDRF
The Eat to Give &
Gas Up to Give Program
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Charity/Non-profit group you are supporting *

   
   
   
Name:
Email:* (please provide your email for essential informational updates).
Address:* (Where you want your cards mailed to.)
Phone:*
City:
Province:
Postal Code:
To calculate the amount of your cards/certificates order, multiply your weekly purchases by 4. Example: If you spend $125 per week on groceries, you would order $500 in Eat to Give TM cards/certificates. If you spend $50 a week on gas you would order $200 in Gas Up to Give™ cards/certificates. After writing in the amount to be debited, choose the number and denomination of cards/certificates you would like to receive.
Amount to be Debited: (minimum order $250 in grocery cards/certificates required excluding gas cards)

EAT TO GIVE™
Central Fresh Market $25x $50x $100x
Hometown Grocers Co‑Op $25x $50x $100x
(Chelsey Grocery Store, Drayton Foodmarket, L&M Arthur, L&M Durham, Knechtel Food Market – Lucknow, L&M Elora, L&M Harriston, L&M Palmerston)
Loblaws $25x $50x $100x $250x
(Loblaws, Zehrs, No Frills, Value Mart, bloorstreet Market, Fortinos, Your Independent Grocer, Extra Foods, The Real Canadian Superstore & Wholesale Clubs, Maxi & Co, Provigo, Atlantic Superstore, SaveEasy & Super Value)
Longos $20x $50x
Metro/Food Basics $25x $50x $100x
(Metro, A&P, Dominion, Loeb, Ultra Food/Drug, The Barn, Food Basics)
M & M's $25x $50x
Safeway $25x $50x $100x $250x
Save-on-Foods $25x $50x $100x   
Sobey’s/Foodland $25x $50x $100x $250x
(Sobeys, Foodland, Price Chopper, IGA, Knechtels, Town, Omni, Boni Choix, Tradition, Commissio's, Fresh co)
Shoppers Drug Mart $25x $50x
Tim Horton's $15x $25x $50x

GAS UP TO GIVE™
Canadian Tire $25x $50x $100x
 (Gas and Store)
Chevron $25x
 (gift certificates)
Esso $25x $50x $100x
Husky $25x $50x
Petro Canada $25x $50x $100x
Pioneer $25x $50x $100x
Ultramar $25x $50x

 

Payment Preference:
Cheque
PAP from Bank Account Option
please either enclose a blank, voided cheque, or fill in the following information.
Name of Financial Institution:
Branch Address:
Branch number: (five digits)
Institution number: (three digits)
Account number: (maximum of twelve digits)
Withdraw Funds
 Full amount on 1st of month
  1/2 of amount on 1st and 15th of month
 Weekly on 1st, 8th, 15th and 22nd of month (minimum $500 order)

I/we the undersigned authorize Community Charity Services to debit my/our account at the Financial Institution indicated. Under the terms and conditions agreed
by me/us with Community Charity Services until such time as written notice to the contrary is given by me/us to CCS. Please Note: You can change the details
of your PAP with 30 days e-mailed/written notice from the date of your first monthly withdrawal.
Registration Forms can be mailed or faxed. Email: CCS at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

Mailing Address: CCS, 25 Industrial Drive Suite 7A, Elmira, Ontario N3B 3K3

Phone: 1-519-669-1081 or 1-866-669-2276 Fax: 1-519-669-2573.

I/we have read and understood the terms and conditions and hereby accept them as a condition of my/our participation in PAP Account

Note : $500 minimum order.

Credit Card Option - (Minimum Order of $500 in groceries for this payment option)
 
Name:
Address:
City:
Postal Code:
Card type: Visa  MasterCard
Card number:
Expiry Date:

Name on card:
Post Dated Cheque (enclosed) Option
 		  
Name:
Address:
City:
Postal Code:

Your card/certificate mailing day will be confirmed in your welcome letter. Canada Post's mailing standard is 5 business days - not including your mailing day, week-ends, or holidays. Your cards may be delivered up to 7 days after your mailing day (CCS is not responsible for any delays as delivery is handled by Canada Post). If cards are lost or stolen in transit CCS will replace them.

Please note: CCS is not responsible for lost or stolen cards/certificates once they are mailed to you and in your possession.

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