POMPIERS AUXILIAIRES DE MONTRÉAL FUNDRAISER Identification First Name* Last Name* Email* Phone number* Grade Please tick your rank or your administrative function and indicate your barracks and group number. For the general staff please indicate your denomination. Firefighter Lieutenant Captain Team leader Operations manager Head of Division Barracks* Team* —Please choose an option—A-1A-2B-3B-4 Senior Staff Deduction per pay Payroll number* New membership Modification to the contribution Check the box that applies to you. 2.00$ 3.00$ 4.00$ 5.00$ Signature I consent to apply the deduction at source. Clear If you have any questions, please do not hesitate to contact us by email at email@example.com We thank you for your generosity and support..