Brisbane Office 800 Kingsford Smith Drive PO Box 1167 Eagle Farm Qld 4009 t 07 3632 2222 f 07 3632 2299 e info@suqld.org.au
CREDIT CARD DEDUCTION
Date: ____ /____ / ________
Name to appear on receipts
(you may nominate business or company trading names):
__________________________________________________________________________________________________________________________
Donor Reference:
(6 digit reference code located at the bottom right of receipts)
Name of donor(s) : Address: Suburb: Phone (w): Email(s):
Please debit $ Once off Monthly from the above account each: Quarterly Half Yearly Annually Other:
State: Phone (h):
Postcode: Phone (m):
CREDIT CARD DETAILS:
Card issuer: Name on card:
Visa
MasterCard
Diner
AMEX
Card number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Expiry date: __ __ / __ __ Signature:
PLEASE ALLOCATE MY DONATION TO:
Cooloola Schools Chaplaincy
$ $ $ $ $
Please note: You will receive an End of Year receipt for all your donations during the financial year by the 2nd week of July. If you would prefer to receive a donation receipt for each donation, please tick here □
4/26/2007 X:\Forms\Source\Credit Card Deduction.doc