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):
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 : Money Donation (Single)
  (minimum $8.00 due to banking requirements)
Money Donation (Regular Pledge to Epilepsy Champions Club)
  (minimum $8.00 due to banking requirements)
Raffle Tickets ($15 per Book of 6 tickets)
Megan Meals Cookbooks  ($15 incl $5 p&h)
If Raffle Tickets/Cookbook Selected:   Number of Raffle Books/Cookbooks Required:   


Optional Information
(Please complete 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 Memory or in Honour of:
 
Transaction Details
 
Transaction Amount ($AUD): $  *
Frequency (Only if Pledge Donation): Monthly    Quarterly    Yearly 
Card Type:   *
Name on Card:   *
Credit Card Number (No Spaces):   *
Expiry Date (mm/yyyy): /   *