Donate - CHOC - Childhood Cancer Foundation South Africa

Fields marked with an asterisk (*) are mandatory

Name

Surname*

First Names*

Title

Contact Details

Tel-work (please include code)

Tel-home (please include code)

Cell

Postal Address

Post Code

Method of Donation

Method of Payment*

Cash Credit Card Internet Payment Stop Order

18A Donations Certificate will be issued for amounts over R5 000 only

18A Donations Receipt?

Yes No

CASH: please deposit into the following account & fax us the deposit slip along with this filled in form:
Standard Bank, Killarney Branch
Branch sort code: 00 72 05
Current Account Number: 20 027 806 1
Name: CHOC Childhood Cancer Foundation South Africa.

CREDIT CARD: Please supply the following details, sign below & return to us:
Visa MasterCard (please select one)
Name on Credit Card:
Credit Card No:
Expiry Date:
CVC No (last 3 digits on back of card):
Signature:

INTERNET PAYMENT: please transfer into the following account & fax/email us the proof of payment, along with this filled in form:
Standard Bank, Killarney Branch
Branch sort code: 00 72 05
Current Account Number: 20 027 806 1
Name: CHOC Childhood Cancer Foundation South Africa.

STOP ORDER: Please set this up with your bank and inform us by filling in this form and faxing/emailing back to us.

CHOC Childhood Cancer Foundation keeps a database of all its donors and sponsors so that they may be informed of any future interesting CHOC activities. Please indicate by ticking the appropriate box whether you would like to stay in touch with CHOC in this way.

Include in our database?*

Yes No

(*) Mandatory field