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Yes, I would like to support the Epilepsy Foundation of South Australia in achieving its goals. My gift is for $..................... Please find enclosed my cheque/money order or Debit $.....................from my
Card No................/................/................/................ Name on card.......................................................... Expiry Date................/................ Signature................................................................. Please note: The Epilepsy Foundation of South Australia is unable to accept credit card payments by email. DonorDetailsTitle Dr/ Mr / Mrs / MsFirst Name................................................................ Surname................................................................... Organisation.............................................................. Address.................................................................... Suburb............................................. State................ Postcode.................................................................. Phone (daytime)........................................................ Fax.......................................................................... Email....................................................................... Please
mail: Epilepsy Foundation of South Australia,
P O Box 12, Woodville SA 5011 *Donations of $2.00 and over are Tax deductible
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