Online Donations

Personal Details
 
*  Items marked with an asterisk must be completed.
 
Title: (Mr,Mrs,Dr etc.)   *
First Name:   *
Surname:   *
Company(if applicable):
Position (if applicable):
Address:   *
 
Suburb:   *
State:   *
Postcode:   *
Country:
Email Address :
Telephone (work):
Telephone (home):
Telephone (mobile):
Please check this box if you would prefer we didn't write to you at this address:  
(you may inform us at any time if you would like to be removed from our mailing list)

If you have donated before and know your Donor No. please enter this number in the box below.

Donor No. (if known):
Select Transaction Type : Donation to Current Appeal
  (minimum $8.00 due to banking requirements)
General Donation (Single)
  (minimum $8.00 due to banking requirements)
Recurring Donation (Regular Pledge to Epilepsy Champions Club)
Frequency Monthly    Quarterly    Yearly 
  (minimum $8.00 due to banking requirements)
Megan Meals Cookbooks  ($15 incl $5 p&h)
  Number Required:   
In Memory of ...
In Honour of ...
Optional Information
(Please complete name if you are making a donation on behalf of someone who has died
or if someone has asked for donation be made instead of a gift to them in box above)


 
Transaction Details
 
Transaction Amount ($AUD): $  *
Card Type:   *
Name on Card:   *
Credit Card Number (No Spaces):   *
Expiry Date (mm/yyyy): /   *