FILL OUT ALL DETAILS THEN PRINT OUT AUTOMATIC BANKING REGULAR GIVER FORM C:
and submit by fax or post to nearest Creation Research Office below:
FORM
C
-
AUTOMATIC BANKING REGULAR GIVER DETAILS:
I understand I can cancel this authorisation at any time by completing and submitting
CANCEL BOX
below.
I AUTHORISE Creation Research to debit my bank account:
*
Date:
Day
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Month
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February
March
April
May
June
July
August
September
October
November
December
Year
-
2004
2005
2006
2007
2008
Select option:
-
WEEKLY
MONTHLY
YEARLY
*
For the amount of:
*
Currency type eg.$us
1.
BANK
DETAILS
*
Bank name:
*
Bank number:
*
Account number:
*
Signature of Acc. holder:
___________________________
*
Date authorised:
Day
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2
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Month
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January
February
March
April
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June
July
August
September
October
November
December
Year
-
2004
2005
2006
2007
2008
2.
DONOR DETAILS
*
Name:
Mr
Miss
Mrs
Ms
Dr
Rev
*
Address:
*
Suburb:
*
State/Province:
*
Country
*
Zip/Postcode
:
3
.
CONTACT DETAILS
Work Phone:
AH Phone
Fax:
*
Email
WWW:
TO CANCEL REGULAR AUTOMATIC BANK DONATIONS FILL OUT DETAILS BELOW:
Select option:
Please cancel my
regular bank gifts to Creation Research
Print Name:
Date Cancelled:
Day
-
01
02
03
04
05
06
07
08
09
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12
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31
Month
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January
February
March
April
May
June
July
August
September
October
November
December
Year
-
2004
2005
2006
2007
2008
Signature:
________________________________
C
OMMENTS (optional)
4
Comments
AUSTRALIA:
P.O. Box 260 CAPALABA Q. 4157. Ph. (07) 3206 4467 Fax. (07) 3206 0001
USA:
P.O. Box 281 Hartsville TN 37074. Ph./Fax. (615) 374 3693
UK:
P.O. Box 1 Ashton-U-Lyne Lancs. 0L6 9WW Phone/Fax. (0161) 282 1111
NZ:
P.O.Box 40480 Glenfield Auckland. Ph. (09) 476 8603 Fax: (09)476 8605
CANADA:
P.O. Box 35027 London ONT N5W 5E3. Ph. (905) 686 7782 Fax. (905) 686 0892
