Donation Form

If you like to make a Donation to our Association. Print out this form and post it to
To
'Australian Speak Easy Association'
National Treasurer
PO Box 114
MOUNT OMMANEY QLD 4074

Title & first names:Mr/Mrs/Ms .........................................Phone (home):(......) ........................

Last name:........................................ Postal address:.......................................................

................................................................................................(Post Code) __ __ __ __

Email: .............................................

I enclose a cheque for a donation of $ ____________________ ( ).tick if receipt required)

or charge $ ____________________to the following card: ( ) Bankcard ( ) Master Card ( ) VISA

Name on card: __________________________ Card No: __ __ __ __ . __ __ __ __. __ __ __ __. __ __ __ __

Expiry Date ______/______ Signature: _____________________________

("The ASEA is a registered Public Benevolant Institution (DRG 486 946)")
("Donations over $2 are tax deductible")

Cheques should be made payable to 'Australian Speak Easy Association' or 'ASEA'