Fundraising Donation Form - PDF

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Fundraising Donation Form - PDF Powered By Docstoc
					                                                                                                    Donation Form

Telephone                       Fax                          Mail                                      Email
9.00am-5.00pm                   Complete and fax this        Irish Cancer Society                      Email the details below to
Monday – Friday                 form to 01 2310 555          43/45 Northumberland Rd                   fundraising@irishcancer.ie
CallSave 1850 60 60 60                                       FREEPOST
                                                             Dublin 4
PLEASE PRINT CLEARLY IN BLOCK LETTERS:

CONTACT INFORMATION:
 Title (Mr, Mrs, Ms, Dr, etc)
 First Name                                              Surname
 Company (if applicable)
 Address


 Telephone (day)                                 (evening)                                          (mobile)
 Email
 If you have donated before and know your Donor Reference No. please enter here

DONATION DETAILS:
Please direct my gift to:                                                                                      where appropriate
  >    Unrestricted (we will determine where your donation can have the greatest impact)
  >    Action Breast Cancer
  >    Action Prostate Cancer
  >    Cancer Research Ireland
  >    Daffodil Day
  >    Pink Ribbon Day
  >    Fundraising Event (please state reference no.&/or event name)
  >    Other (please state)

Gift type:                                                                                                     where appropriate
  >    General
  >    In Memory Donation (Please complete details for Tribute Card over page)
  >    Special Occasion Donation (Please complete details for Celebration Card over page)


PAYMENT DETAILS:
       I enclose a cheque/money order/postal order for the amount of € ______________________________
       (crossed & made payable to Irish Cancer Society. Please do not send cash in the post)

OR: Please debit my:             Visa           MasterCard           Amex                Laser Card

For the amount of:          € _______________________________

Name on Card:               ___________________________________                 Signature: ______________________

Card Number:     ⊔⊔⊔⊔ ⊔⊔⊔⊔ ⊔⊔⊔⊔ ⊔⊔⊔⊔ ⊔⊔⊔                                  Extra laser card digits
                                                                                                     Expiry Date:   ⊔⊔ ⊔⊔
OFFICE USE ONLY:
 Ref No.                                Date Card Disp                                     Processed by


                                  43/45 Northumberland Road, Dublin 4, Ireland CallSave: 1850 60 60 60 Fax: 01 231 0555
DONATEFORM 06.12.2007                                              Email: fundraising@irishcancer.ie www.cancer.ie
                                                                        Donation Form cont’d

PLEASE PRINT CLEARLY IN BLOCK LETTERS:


IN MEMORY DONATION

– DETAILS FOR TRIBUTE CARD


 This donation is in memory of (Name)
 Names of people making gift
 Card to be delivered to (Name/s)
 Address




 SPECIAL OCCASION DONATION

 – DETAILS FOR CELEBRATION CARD


 This donation is made in honour of (Name)
 Special Occasion (Anniversary/Birthday, etc.)
 Names of people making gift
 Card to be delivered to (Name/s)
 Address




                               43/45 Northumberland Road, Dublin 4, Ireland CallSave: 1850 60 60 60 Fax: 01 231 0555
DONATEFORM 06.12.2007                                           Email: fundraising@irishcancer.ie www.cancer.ie

				
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