Research Donation Form

 

CLIFFORD CRAIG MEDICAL TRUST DONATION FORM





Please accept my donation (please circle)   $50  $100  $250  $500  Gift of Choice $___

My cheque is enclosed or debit my        Visa          Mastercard        Bankcard

 

Name ...................................................           Email Address ..................................

Address ................................................          Telephone Number ...........................

.............................................................   

State …………………… Post Code ..................     

     

Cardholders Name ............................

Card Number …………/…………./…………../…………../

Expiry Date …………../…………

Cardholders Signature ............................................



Please post to either:

 


The Lupus Association of Tasmania inc.

Registered Charity – ABN 96 163 951 956

PO Box 639 Launceston TAS 7250

Email:  lupustas@bigpond.net.au

Website:  www.lupustas.bigpondhosting.com


The Clifford Craig Medical Research Trust

PO Box 1963 Launceston TAS 7250

Telephone:  (03) 6348 7010

Email:  enquiries@cliffordcraig.org.au

Website:  www.cliffordcraig.org.au