The Sir Henry Royce Foundation - Benefactor Application Form

The
Sir Henry Royce
Foundation

Benefactor Application Form

Please print out this form and fill in the blanks before posting or faxing.

I wish to support the work of the Sir Henry Royce Foundation, Australia as:

Please tick
your choice. Level Donation

    Platinum Benefactor $5000

    Gold Benefactor $2000

    Silver Benefactor $500

    Friend of the Foundation $10 (or more) p.a.

Please tick your choice.	Level	Donation
	Platinum Benefactor	$5000
	Gold Benefactor	$2000
	Silver Benefactor	$500
	Friend of the Foundation	$10 (or more) p.a.

My cheque is attached or please charge my Visa/Mastercard/Bankcard using the details below.

Credit Card Details

Card Number: Expiry

Name on Card:

Mailing Address
Please forward the receipt to:

Name:

Street:

Suburb:

Postcode:

State:

Country:

Optional Details for Order Confirmation only

e-mail:

Telephone:

Please post your order to:

Ms Jennie Wickham
The Sir Henry Royce Foundation
Locked Bag 888
St Kilda Road Central
Victoria 3004
Australia

Or fax to: Australia: (03) 9529 4315
International: +613 9529 4315

Name:
Street:
Suburb:
Postcode:
State:
Country:
Optional Details for Order Confirmation only
e-mail:
Telephone:

Please post your order to:	Ms Jennie Wickham The Sir Henry Royce Foundation Locked Bag 888 St Kilda Road Central Victoria 3004 Australia
Or fax to:	Australia: (03) 9529 4315 International: +613 9529 4315

TheSir Henry RoyceFoundation

Benefactor Application Form

The
Sir Henry Royce
Foundation