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.......................................................................