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Donation
Form
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
 |
Bankcard |
 |
Visa |
 |
AMEX
|
 |
Mastercard |
 |
Diners |
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.
Donor
Details
Title Dr/ Mr / Mrs / Ms
First
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
Or
Fax (08) 8445 6387
*Donations
of $2.00 and over are Tax deductible
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