PLEASE PRINT THIS FORM AND SEND TO THE ADDRESS BELOW

Konstanty (Kot) Piekarski
"Umykając piekłu"- First Polish Edition

(English edition of "Escaping Hell" also available in limited quantities)

No. of copies:
$20CDN
Total:  $CAN           CURRENCY CONVERTER
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Address :
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E-mail:

Please make your cheque payable to: Konstanty Piekarski Memorial Foundation.

You can also make a direct deposit to:
Canadian Imperial Bank of Commerce (CIBC)
3070 Sunridge Boulevard NE
Calgary, Alberta
T1Y 7G6
Canada
Account no. 07029-010-5109019

Please send this form, your cheque or proof of funds deposited, to the address below:
Konstanty Piekarski Memorial Foundation
650 - 26 Avenue NW
Calgary, Alberta
T2M 2E5
Canada
mailto: pulwicki@shaw.ca

Thank you for your order and generous donation. Your donation of $20CAN and up
is tax deductible and the receipt will be sent to you promptly (Canada only).

Prosimy o poparcie działań naszej Fundacji przez dołączenie dotacji pieniężnej do tego zamówienia.

Please support the endeavours of this Foundation and send your donation.