| Please print this form and return it to: |
North Shore Hospital Foundation P.O. Box 93503 Takapuna Auckland |
Personal Details
Yes, I would like to make a donation to the North Shore Hospital Foundation project fund.
Donation Details
Credit Card - Please fill in the details below
Type of Donation:
Cash, Cheque or Credit Card
I would like to donate: $--------------------
Title: ---------
First Name: ---------------------------
Surname: -----------------------------
Home Phone: -------------------------
Address: -----------------------------
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Suburb: ------------------------------
City: ------------------------------
Country: --------------------------
Post Code: ------------------------
Email: ------------------------------
Company (if applicable): --------------
Position: -----------------------------
Work Phone: -------------------------
Cheque - Please attach cheque to form and make them payable to: North Shore Hospital Foundation
Bequest and Endowments
In-kind donation
Sponsorship
Amex
Diners
Visa
Mastercard
Card number:
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Expiry date:
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Signature:
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Name on card:
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