ASH Australia donation / financial support form

Name      ...............................................................................................................

Position  ................................................................................................................

Organisation ..........................................................................................................

Address .................................................................................................................

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

Suburb    ................................................................................................................

State       ............................................................   Postcode  .................................

Telephone (A/hours)  ..................................     (Business) ........................................

Mobile   .....................................................    Email  ...............................................

I wish to make a donation of  $25    $50    $75

Other specified amount  $ .............................................

I wish to receive an official ASH Certificate of Recognition & Appreciation

$150 Bronze supporter   $500 silver supporter   $1000 Gold supporter

Please include my name in a supporters list on the ASH website and Annual Report

I wish to pay by cheque, made payable to ASH Australia (mark cheques "non-negotiable"), 

OR   please debit my Visa card   Mastercard   Bankcard

Card No 


Expiry     

Name of card holder  ...........................................................................................

Signature  ..........................................................................................................

  Please send me details of how I can include a legacy to ASH in my will

Please print and send this coupon with your donation to  
ASH PO Box 572 KINGS CROSS NSW 1340,
or phone (02) 9334-1876 or (02) 9334-1843 with your details and we will forward a receipt.

 Page last updated on 9/3/07