Make a Transformative Gift Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email Named Dedication opportunities are available for the following areas:Foyer ($500,000) Artist's Green Room ($50,000)Two Dressing Rooms ($25,000 per room)Campaign Recognition Wall ($15,000)Please contact VAM to discuss your interest A Gift of Securities donation to the Campaign is very much welcomed. Please contact VAM for details and transfer information. By becoming a Seat Tribute Donor, you will play an outstanding role in seating future audiences. I wish to become a Seat Tribute Donor at $1,000 per seat Seat Donation to the Koerner Recital Hall Campaign* Price: $ 1,000.00 CAD Quantity: With a donation in any amount meaningful to you, your contribution will stand as a legacy for generations of young musicians and concert audiences.Donation Amount* Yes! I'm interested in becoming a monthly donor. Please charge the above amount to my credit card each month. The Vancouver Academy of Music is authorized to charge my credit card:until May 2017until end-date before May 2017Campaign spans May 2016 to May 2017Please specify end-date:* Please charge my card on the ___ day of the month1st15thOptional: I would like to dedicate this donation as a giftin Honourin MemoryI would like this gift to be in honour/memory of:Please send an acknowledgement of my gift to (optional):Please include a name & address.The name(s) I wish to use in donor acknowledgements: I wish to remain Anonymous. Total $ 0.00 CAD Credit Card MasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name Additional Comments?Vancouver Academy of MusicCharitable Registration Number: 10816 6240 RR0001CommentsThis field is for validation purposes and should be left unchanged.