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The information on this form is collected by the Northern Ontario School of Medicine, as the faculty of Medicine for Laurentian University and Lakehead University, for the purpose of fundraising and related activities. The Northern Ontario School of Medicine respects the privacy of our donors and will use your personal information only for the purpose of fundraising and related activities including providing charitable donation receipts, contacting you regarding your gift, and keeping you informed of other School, Alumni or Advancement events and activities. Information collected may be shared with Laurentian University or Lakehead University. Any questions about the collection, use, and disclosure of this information should be directed to the Manager of Advancementt, Northern Ontario School of Medicine , 955 Oliver Road, Thunder Bay Ontario P7B 5E1, 807 766 7300 You may ask at any time that we no longer use or disclose your personal information for a fundraising purpose.

Charitable Registration Number 864660352 RR0001.

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