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Organisation Contact Details

Appeal Name:	The Conservation Council, the community voice for the environment in Canberra since 1979.
Organisation Name:	Conservation Council of ACT Region
Address:	GPO Box 544 CANBERRA ACT 2604
Fax:	02 6248 5343
Phone:	02 6229 3202

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Donor Details — Please Print Clearly

	Tick if you would like to remain anonymous (NB A tax invoice will not be sent)
Name:	Title	First Name	Last Name
Address:
	Suburb	State	Postcode
Phone:	Home	Work
	Mobile	Fax
Email:

Payment Details — Please Print Clearly

I would like to donate		$	to Conservation Council of ACT Region
	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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