Please accept my gift of: $____________________
Donation to:
[ ] Doorway of Hope Appeal
[ ] Disaster Relief
[ ] Christmas Appeal
[ ] Other (please specify) ___________________
Please select your method of payment:
[ ] Money order
[ ] My cheque is enclosed marked 'Not Negotiable' and payable to 'Rock Community Care Inc. Gift Fund'
[ ] Please debit my credit card:
Select [ ] Bankcard [ ] Mastercard [ ] Visa
Credit card Number:
_____ /_____ /_____ /_____
Name on credit card:
_____________________________
Expiry Date:
___ /___
Signed:________________________________
Surname:_______________________________
First name: _____________________________
Address: ______________________________
Suburb/Town:__________________________
State:_________________________________
Postcode: _____________________________
Telephone:
( ____ ) ______________________________
Fax:
( ____ ) ______________________________
Mobile:
_____________________________________
Email:
_____________________________________
Tick here for more information regarding:
[ ] Direct debit options for regular contributions
[ ] Remembering Rock Community Care Inc. in my Will
[ ] Free information booklets on making a Will
-----------------------------------------------------------------------------------------------------------------------------------
Thank you for your kindness in supporting Rock Community Care Inc.