Leukodystrophy Australia Recurring Credit Card Donation Form

Your Full Name*

First NameLast Name

Your Contact Phone Number*

Your Email*

Confirmation Email

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Payment Method

Credit Card (Visa, Mastercard, Amex)Cheque made out to Leukodystrophy AustraliaDirect Debit BSB: 193-879 Acc No: 457864204

Membership Type (online payment)

Membership - (for people who are directly affected by Leukodystrophy)$ FreeAUD

Membership - Annual Subscription$25.00AUD

Members’ Quarterly Newsletter - (Emailed)$ FreeAUD

Members’ seasonal Newsletter via Australia Post$25.00AUD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Thank you for your planned membership by Direct Deposit or Cheque. This process requires you to either post a cheque, or complete your donation via your own online banking.

Direct Deposit details:

Bank of Melbourne
Australian Leukodystrophy Support Group Inc
BSB: 193 879
A/C: 457864204
Please enter your name in the Reference field.

Cheque:

Payee: Australian Leukodystrophy Support Group Inc

Mailed to:

Leukodystrophy Australia
P O Box 2550,
Mount Waverley
VICTORIA 3149
AUSTRALIA

Membership Type

Membership - FREE (for people who are directly affected by Leukodystrophy)Membership - Annual Subscription - $25.00Members’ Quarterly Newsletter - FREE (Emailed)Members’ seasonal Newsletter via Australia Post - $25.00

Important: Please read the information below about membership eligibility, benefits and responsibilities, and legal requirements relating to the Leukodystrophy membership register.

Peer Support

I wish to offer Peer Support.I would like to obtain Peer Support.

I would like contact to find out more about possible future Committee or volunteering in some way.

Yes, pleaseNo, thanks

Briefly outline any skills and experience relevant to this role:

Please let us know the type of Leukodystrophy affecting your family or any other information you would like to share:

Please complete the following security check to prove you are not a robot*

To cancel a recurring membership, please contact us by email or phone and we will handle this offline.

PE TEST FORM ONLY