Pledge Form

Print off the form, complete and post or fax it to Courage International. Or if you prefer you can ring 1300 55 0096 (Local call)
Courage International
PO Box 183
Greenock
SA 5360
Fax: 1300 55 0097


Personal Details
Name :
Address - Street:
Suburb:
State:
Postcode:
Ph:
Fax:
Email:


I want to support Courage International on a regular basis by:

Cheque

Direct Deposit
Please send a direct deposit book so that I can deposit donations directly into Courage's bank account.

Automatic periodical payment.

I have arranged an automatic periodical payment from my bank account to Courage International Donations account
Amount: $
Date Commenced:
Period: Monthly Other:
If Other selected please specify:


Automatic credit card debit
Please automatically debit my credit card for the amount
of $ per month until advised otherwise
Credit card type: Bankcard Visa Master Card AMEX Diners

Card Number :
Expiry Date : Month January February March April May June July August September October November December Year 2003 2004 2005 2006 2007 2008 2009 2010

Please add your signature when you have printed this form
__________________________________________
Signature