Please print out and complete the following form:
 

Yes, I would like to make a donation to Retina Australia (NSW) Inc to give The Gift Of Sight
 

 o $25      o  $50    o $100   o $500     o Other   $_____

Please debit my card with $_________ 

CARD NUMBER  _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _

EXPIRY DATE  _ _  / _ _

NAME ON CARD_______________________________________

Regular Giving

Please debit my card with $______ per month starting on  _ _ / _ _ /  _ _ _ _

CARD NUMBER  _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _

EXPIRY DATE  _ _  / _ _

NAME ON CARD_______________________________________ ____

SIGNATURE

Direct Debit Guarantee: Charity specific

Name__________________________________________________

Address ________________________________________________

Email address____________________________________________

Phone Number:_____________ Mobile: ______________________

All donations over $2 are tax deductible

THANK YOU FOR YOUR GIFT

Please return your completed form TODAY to:

Retina Australia (NSW) Inc

GPO Box 397, Strathfield  NSW  2135

 

ABN: 84 156 512 431    

Phone: 02 9744 7738      

Fax: 02 9715 1314       

Email: president@retinaaustraliansw.com.au

RANSW respects your privacy.   We do not disclose personal contact information without permission.

o  Please remove my name from your mailing list. 12/2007

For information call our toll-free number:
1800 999 870
Monday-Friday 9am-5pm EST
or email secretary@retinaaustraliansw.com.au