PLEDGE FORM

Full Name

Prefix First Name Last Name

Email

example@example.com

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mobile Number

- Country Code Mobile Number

My PLEDGE I/we would like to make a monthly donation, for the next 12 months, of:

$2000 $1000 $500 $250 $100 $50

Enter the message as it's shown *

E-mail addresses and other personal information

bic.org.au will only record your e-mail address and personal information if you supply it to us, either by sending a message or completing and submitting a form.

The use of these applications requires the user to provide personal information. This information will be used only for the purpose for which you have provided it and will not be added to a mailing list unless you have asked us to. Nor will it be disclosed or redistributed unless it is authorized or required by an Australian law, court or tribunal order or you provide consent/permission to do so.