Donation Form

Yes, I would like to support the Epilepsy Association of SA & NT in achieving its goals.

My gift is for $__________

Please find enclosed my cheque/money order or

Debit $_______ from my (please tick one)

__ Bankcard.. __Visa.. __Mastercard.. __AMEX.. __Diners

Card No ________/________/________/________

Name on card ______________________________

Expiry Date ________/________

Signature __________________________________

Please note: The Epilepsy Association is unable to accept credit card payments by email.

Donor Details

Title Dr/ Mr / Mrs / Ms

First Name ______________________________

Surname ______________________________

Organisation ______________________________

Address ______________________________

Suburb _______________________ State _________

Postcode __________

Phone (daytime) __________

Fax __________

Email ______________________________

Please forward to:
Epilepsy Association of SA & NT,
P O Box 12,
Woodville SA 5011

Or

Fax 08 8445 6387

Donations of $2.00 and over are Tax deductible