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Food4Everyone (Poverty Aid for Cambodia), Heartland International
ABN: 27 111 873 404
Suite 106, 64-68 Derby Street
PENRITH NSW 2750
Phone: 4737 3400
Mobile: 0401 06 5979
Please accept my/our donation:
Please fill in so we can send you a receipt for taxation purposes.
Name:___________________________________________________________________________
Postal Address:___________________________________________________________________
________________________________________________Post Code:_______________________
Phone:____________________________ Email:_________________________________________
Donation Amount: $_____________________________________________
Payment Options: (please circle) Credit Card / Cash - please see host
Please complete:
Name on Card:___________________________________________
Card Number:___________/___________/__________/__________
Expiry Date: ________/________ Circle One: VISA / Master Card:
Signature: ___________________________________________
All donations will appear on your credit card statement as “Global Development Group”, who support our project. All donations are of course tax deductible.
Office Use only:
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Credit card detailed
Checked:
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Cash received by:
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Postal address checked
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