Australian Republican Movement

Print donation form

If you would like to make a donation to the Australian Republican Movement, simply print out this form and fill it in. If you are paying by credit card, you may fax the form to us on (02) 9267 8155. If you wish to post the form to us, include your cheque, credit card number or money order and post it to:

Australian Republican Movement
PO Box A870
Sydney South NSW 1235

DONATION

     Tick this box if you wish to remain anonymous (your details must still be entered but 
            will be kept strictly confidential)

Mrs / Miss / Ms / Mr / Dr ______________________________________________________                          

Address __________________________________________________________________                          

_________________________________________________________________________

State/Territory _____________________ Postcode _____________________

Tel Home ( ) ___________________ Work ( ) ___________________


 Amount of Donation $________________

       Cheque (Payable to Australian Republican Movement) 

       Money Order 

       Credit Card


For credit card donations, please complete the following authority:                          

       I, _____________________, authorise the Australian Republican Movement to debit my 
                credit card for the amount indicated above as a donation to the organisation. 

       I, _____________________, authorise the Australian Republican Movement to debit my
                credit card for $_______on the first business day of each calendar month.

     BANKCARD                   MASTERCARD                 VISA


Name on card __________________________________________________________


Card number


Expiry date                         Signature on card

   /           ____________________________________