Please print this form, complete the details and fax or mail to the following details:

    

Stop Demand Foundation
P.O Box 41-400, St Lukes
Auckland
New Zealand
Fax: +64 9 846 7614



Date: ______________

 Contact Details

First Name:   Last Name:  

Company:
 
Email:
 

Phone:
 
Fax:
 

Address:   City:  
State /
Province:
 
Postal Code:
 

Country:
 
 

 Your Donation

Donation Method:
Cheque/Check
Credit Card 

Donation amount:

NZ$______________
Donation Frequency:  
Once only
Monthly until notified
Annually until notified 

 

 Credit Card Details

Credit Card:
Visa
Master Card
Amex
Diners

Name On Card
 
Card Number:
 

Expiry Date:
 
Sign: