NORTH EASTMAN HEALTH ASSOCIATION INC

NORTH EASTMAN HEALTH ASSOCIATION INC.

DONOR SPECIFICATION FORM

(The donation fund is used for purchases that are typically not funded
through Manitoba Health. It may include purchases of equipment,
enhancements to the décor of the facility or grounds, etc.)

Date: ________________________________

Name: ________________________________

Address: ________________________________
________________________________

Amount of Donation: ________________________________

Please place a check mark beside one of the following:

1. ____ I wish to contribute to the REGIONAL DONATION FUND
2. ____ I wish to specify my donation be used for:
Please mark the site "Ö " you wish to donate to if applicable:
___Beausejour Health Centre
___East-Gate Lodge PCH
___Pinawa Hospital
___Pine Falls Health Complex
___Kin Place Health Complex
___Lac du Bonnet PCH
___Lac du Bonnet Health Centre
___Whitemouth District Health Centre
___Other Service or Program______________________________ (please specify)

3. ____ I wish to meet with a facility/program manager to discuss

Donations can be forwarded to Corporate Office:
North Eastman Health Association Inc.
24 Aberdeen Avenue
Box 339
Pinawa, MB R0E 1L0

Date:	________________________________
Name:	________________________________
Address:	________________________________
	________________________________
Amount of Donation:	________________________________