Leukodystrophy Australia Recurring Credit Card Donation Form

PE TEST FORM ONLY
Your Full Name *

First Name Last Name
Your Contact Phone Number *
Your Email *

Confirmation Email
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Payment Method

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

Membership Type (online payment)

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

Membership - Annual Subscription $ 25.00 AUD

Members’ Quarterly Newsletter - (Emailed) Free

Members’ seasonal Newsletter via Australia Post $ 25.00 AUD

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 - $25.00 Members’ 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, please No, 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.
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

PE TEST FORM ONLY