donation pledge form - anam cara house geelong · 2018-08-20 · cheque - i have attached my/our...
TRANSCRIPT
Donation Pledge Form
YES I wish to support The New Anam Cara Geelong with my total donation of $_________
Pledged over __ years with my First Payment $__________ on __/__/__
Second Payment $__________ on __/__/__ Third Payment $__________ on __/__/__
Signed______________________________ Date___/___/___
My Details
Title:____________First Name:__________________________Last Name:_____________________
Job Title:__________________________________Company:________________________________
Address:___________________________________________________________________________
Suburb:_____________________________________State:______________Postcode____________
Phone: ___________________________________Mobile: __________________________________
Email:_____________________________________________________________________________
Name on Receipt (if different from above):________________________________________________
Payment Method
❑ Credit Card
I authorise Anam Cara Geelong to debit my donation to my:
VISA MasterCard (please circle)
Card Number:
CVC: _ _ _ Expiry: _ _ / _ _ Signed________________________ Date: _ _ / _ _ / _ _ _ _
❑ Cheque - I have attached my/our cheque (Payable to Anam Cara House Geelong Ltd.)
❑ Direct Deposit
Account: Anam Cara House Geelong - Bendigo Bank: BSB 633-000 Account: 163-390-792
(please email [email protected] with your deposit details - reference your Last Name)
❑ In Person - Visit our office at: 142 Myers St Geelong.
*All donations over $2 are tax deductible and will be issued with a receipt.
142 Myers Street | PO Box 681 | Geelong, 3220 | VictoriaT: 03 5222 5831 | F: 03 5229 2383 | E: [email protected] | W: www.achg.org.au
ABN: 41 355 658 648
Donation Pledge Form
