Print out this form and use it to make a donation to Integricare. (CTRL-P)

The Hon Treasurer
Integricare
PO Box 260
Burwood NSW 1805

Yes! I’d like to make a donation towards the work of Integricare.

NAME Mr./Mrs./Ms/Miss/Rev/Dr.............................................................................................

ORGANISATION(If appropriate).........................................................................................

ADDRESS ........................................................................................................................

.................................................................POSTCODE......................................................

TELEPHONE NUMBER....................................................................................

FACSIMILE NUMBER .....................................................................................

E MAIL ADDRESS...........................................................................................

I have attached my cheque/money order for

[ ] $35.00 [ ] $50.00 [ ] $100.00 [ ] $200.00 [ ] Other .............

Alternatively, please charge my: [ ] Mastercard [ ] Visa [ ] Bankcard

Number: [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ]

Name on Card ........................................................ Exp. Date................................

Signature ...............................................................................

[ ] Please send me details about leaving Integricare something in my Will