Glaucoma News - Donations

You Can Help

You may either send the following form electronically (with your credit card details), as this is a secure site, by using the Submit button below or print the form out and either fax it (with your credit card details) to 02 9439 8736 or post it to:

Glaucoma Australia Inc
PO Box 420
Crows Nest NSW 1585

If you have any enquiries please phone us on (02) 9906 6640.

Yes, I would like to assist in the Association's work.

Please check all that apply:

	I would like to make a tax-deductable donation
	$ (Donations over $2.00 are tax deductable)
	I would like to receive some literature on Glaucoma
	I am interested in including the Association in my will

* Denotes required fields

First Name:

Family Name:*

Title:

Address: *

Suburb or City:*

State or Province:*

Postal Code:*

Country:

Home Phone:

Work Phone:

Fax Number:

E-mail:*

Payment Method: Credit Card Money Order Cheque

(please make cheques payable to Glaucoma Australia)

to pay on line using our secure page

For Credit Card users only if posting or faxing

Amex Diners Bankcard Mastercard Visa

Credit Card Number

Name on Credit Card

Exp Date

Signature ______________________________

THANK YOU FOR YOUR SUPPORT

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