Donation
Payment Form
YES,
I would like to assist Karinya in reaching people with affordable counselling
and personal growth services, empowering them to live their lives to the
fullest.
Section 1:
PERSONAL INFORMATION
(Please
complete all fields)
Title:
Miss Ms
Mr
Mrs Dr
Other____
Surname:
____________________________ First
Name: _________________________
Postal
Address: _____________________________________Suburb:___________________
State:
_________ Postcode:
_________
Business Phone: __________ Home Phone: ___________Mobile Phone: _____________
Email Address: ________________________________________________________________
Business Name (if this is the donor):
___________________________________________
Business Address (if this differs from above):
__________________________________
All
of your personal information is private and confidential and will not be given
to any other organization, (please refer to our Privacy Policy for more
information) If you would not like to receive any further correspondence
from Karinya (events and updates) please leave a cross here:
Section
2: TYPE OF SUPPORT BEING OFFERED Please
tick the appropriate boxes and Karinya will contact you with further information
to complete your request.
Cash,
Credit or Cheque Donations. Please complete the details below.
- Direct
Debit Donation
- Workplace
Giving
- Bequest
– Becoming a “Partner for Life”
- Memorial
Gift – Join Karinya’s “Honour Roll”
- Philanthropic
Gift
- In-Kind
Gift
- Pro-Bono
Services
- Employer
Matching Gifts Program
- Staff
Fundraising
- Program
Sponsorship
- Corporate
Community Partnership
-
Volunteering
Section 3:
CREDIT CARD DETAILS
Type
of Card: Bankcard
VISA Master
Card Amex
Diners Club
Card
Number: ____ ____ ____ ____
Name
on the Card: ________________________________________
Card
Expiry Date: __/__
Frequency
of Donation: Once only
Or Periodic
Amount
of Donation: $__________
Signature
Confirming your donation _______________________
Karinya’s
Head office is located at 588 High Street Road, Glen Waverley Vic 3150 Tel: (03)
9802 2886 Fax: (03) 9887 7266
Branch offices are located at Blackburn North and Melton.
Karinya Counselling Centres are an Incorporated, not-for-profit, registered
charity.
ABN 54 876 801 530