Sponsorship / Donation form

DONOR/SPONSOR'S INFORMATION

Name

__________________________________________________________________________

Position:

__________________________________________________________________________

Organisation:

__________________________________________________________________________

Postal address:

__________________________________________________________________________

______________________________________State: __________ Postcode: __________

Email:

__________________________________________________________________________

Phone/Fax:

__________________________________________________________________________

SPONSORSHIP/DONATION INFORMATION

Sponsorship:

[   ] My organisation wants to sponsor this event:

$100         $200         $500         $1000         $2000         Other: $ ______________________

[   ] My organisation is willing to provide in-kind sponsorship in the the follow ways:

__________________________________________________________________________

__________________________________________________________________________

or Donation:

[   ] To ensure the continual viability of this Forum, I would like to donate:

$20         $50         $100         $500         $1000         Other: $ ______________________

Total:

$ ______________________

METHOD OF PAYMENT

Cheques / Money Order

» Enclose Cheque or Money Order payable to ACMICA, PO Box 306, Dulwich Hill NSW 2203.

Cheques/MO processed by ACMICA.

Credit Card

I authorise the Edmund Rice Centre to debit my card:

[   ] VISA
[   ] MasterCard

[   ] BankCard

Card holder name: _______________________________________________________

Card number: ___________________________________________________________

Expiry date: ______________

Authorisation signature: ___________________________________________________

Credit card payments processed by the Edmund Rice Centre.

OFFICE USE ONLY

Amount:

___________________________

Received by:

___________________________

Date received:

___________________________

Ref:

___________________________