2015 World Diabetes Day Swim-a-thon
To ensure that the funds you have raised for Diabetes Queensland are safely
deposited, please choose from one of the following payment methods and
return this form to us so we can provide you with a payment receipt.
Please return to:
Fundraising Coordinator
Diabetes Queensland
GPO Box 9824,
Brisbane Qld 4001
Fax: (07) 3506 0943
Email: fundraising@diabetesqld.org.au
Your Event
Event Name:
2015 World Diabetes Day Swim-a-thon
Event Date: 14/11/2015
Event Details:
Your Details
First Name:
Surname:
Email Address:
Postal Address:
Suburb:
Daytime Phone:
Postcode:
Mobile:
Payment Options
Credit Card
Amount to Charge:
$
Credit Card Type:
Credit Card Number:
Cardholder Name:
Card Expiry Date:
 I understand that my credit card will be charged at the amount stated above which will appear on the credit
card statement in the name of Diabetes Queensland or Diabetics Association of Queensland
Card Holder’s Signature:
Electronic Transfer
Our Bank Details:
Diabetes Queensland
Westpac Bank
BSB 034 013 Account 247497
Amount Deposited:
$
Date Payment Made:
Payment Reference:
Cheque or Money Order
Please make payable
Diabetes Queensland
to:
Amount:
Payment Reference:
$
Date Payment Made: