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Organisation Contact Details

Appeal Name:	ME/CFS Victoria Annual Appeal
Organisation Name:	M E CHRONIC FATIGUE SYNDROME SOCIETY OF VICTORIA INC
Address:	PO Box 7100 DANDENONG VIC 3175
Fax:	(03) 9793 1866
Phone:	(03) 9791 3100

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Donor Details — Please Print Clearly

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Address:
	Suburb	State	Postcode
Phone:	Home	Work
	Mobile	Fax
Email:

Payment Details — Please Print Clearly

I would like to donate		$	to M E CHRONIC FATIGUE SYNDROME SOCIETY OF VICTORIA INC
	Enclosed is my cheque / money order
	Please charge my credit card

Credit Card Details

Card Type:	VISA   Mastercard
Card Number:
Expiry Date:	/	CVV:
Cardholders Name:
Signature:
Date of Donation:

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