| Personal Details | |
| Title: | |
| First Name: | * |
| Last Name: | * |
| Company (if applicable): | |
| Postion (if applicable): | |
| Street: | * |
| Suburb: | * |
| City: | * |
| State/Province: | |
| Postcode/Zip: | |
| Country: | |
| Telephone: | |
| Fax: | |
| Email: | |
| Amount | |
| Amount: | |
| I'll make my gift by: | |
|
If you prefer to send a cheque, please make it out to the Starship Foundation and post to PO Box 9389, Newmarket, Auckland, New Zealand. If possible, please print two copies of this page and return one copy with your cheque. Thank you. |
|
| If your donation is by credit card, please complete the following | |
| Credit card type: | |
| Credit card number: | * |
| Your name as it appears on your credit card: | * |
| Expiry date on card (mm/yy): | |
| Response To | |
| This donation is in response to: | |
|
NZ Herald Child Abuse Series A letter in the mail Starship Television Commercial Reach Out Newsletter Magazine article Other media Misc – not responding to any appeal |
|
| Apply To | |
|
Child Abuse Centre Ella's Pet Cuddle Corner Cancer Ward Appeal Area of greatest need Specific Starship Ward or Unit In Memoriam Donation Other |
|
| Keeping In Contact | |
|
Please indicate which mailings you would like to receive: Regular automatic donations (with a link to the Star Bear Club page) Annual Appeals (2 per year) Starship Log Newsletter (quarterly) Fundraising Events Bequest information I do NOT wish to receive any communication from the Starship Foundation |
|
On behalf of the Starship Foundation, thank you for your invaluable support.