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    I WISH TO DONATE AND HELP SAVE THE GOULDIAN!

         Name:______________________________________

         Address:____________________________________

         Suburb:______________________________________

         State:________________________________________

         Postcode:______________

           Country:______________________________________

  email/www:______________________________________

        Signature:____________________________________

        Date:_________

 
                                  Credit Card Details:    

              Mastercard        Visa       Bankcard
                    

  Expiry Date:   ............./.........

  Amount:   ....................

  Signature: ..................................
 

  Or:  Please Find Enclosed Cheque/Money Order For  $.................................

 

   Please make all cheques/money orders payable to the Save The Gouldian Fund

 

       Please send completed form to:

               SAVE THE GOULDIAN FUND              
       PO BOX 147         
             COORANBONG               
           NSW 2265              
AUSTRALIA

 Further Information email : marcus_pollard@hotmail.com