Village Housing Donation Form |
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| [_] Yes, please accept my gift for Village Housing. |
Please find enclosed my gift of:
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[_] $25 |
[_] $45 |
[_] $60 |
[_] $100 |
[_] $150 |
[_] $275 |
[_] Other $________ |
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| [_] |
Yes, I would like a receipt mailed to me.
Your receipt will be mailed to the postal address you provide below. Donations $2.00 and over are tax deductible. |
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| Name |
_____
(Title) |
____________________
(First name) |
_________________________
(Surname) |
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| Postal Address |
______________________________
(Address Line1) |
______________________________
(Address Line2) |
____________________
(Suburb) |
_________
(State) |
_________
(Postcode) |
______________________________
(Country) |
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| Phone Numbers |
| H: ( ___ ) |
_______________ |
W: ( ___ ) |
_______________ |
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| Email Address |
| __________________________________________________ |
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| Age Group |
| [_] 10 - 17 |
[_] 18 - 24 |
[_] 25 - 39 |
[_] 40 - 54 |
[_] 55+ |
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| [_] |
My cheque / money order is enclosed, crossed 'Not Negotiable' and made payable to
'CLA INC. 804011 01100350'.
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Or, please charge my credit card:
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[_] Visa |
[_] Mastercard |
[_] American Express |
[_] Diners Club |
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| Number |
|__|__|__|__| - |__|__|__|__| - |__|__|__|__| - |__|__|__|__| |
Expiry |
____/____ |
Signature _____________________________ |
Please indicate by ticking the State you wish to make your donation to:
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[_] NSW / ACT |
[_] NT |
[_] QLD |
[_] SA |
[_] TAS |
[_] VIC |
[_] WA |
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Please send this form and your donation to
| [_] Yes, I would like to know more about the direct debit donation program. |
| [_] Please send me more information on making a gift in my Will. |
| On December 21, 2001, the new provisions of the Privacy Amendment (Private Sector) Act 2000 commenced. This legislation updates the Privacy Act of 1988 and is designed to protect your rights with respect to personal information held. Village Housing and Community Living Association Inc. follow these national privacy principles. |
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