Donation for
State Mine Emergency Appeal

Print out, complete and send together with your payment to:

The Secretary, PO Box 617, Lithgow, NSW 2790

Credit Card donations may be faxed to (02) 6353 1185

NAME:________________________________________________

POSTAL ADDRESS:______________________________________

_____________________________________________________

__________________________________POST CODE:_________

Donation is being made by (please tick one):

( ) Money Order, ( ) Cheque, ( ) Bank Cheque ( ) Credit Card

AMOUNT: $______________

If paying by Credit Card, please complete the following:

Card Type: ( ) Bankcard, ( ) VISA card, ( ) Mastercard.

Card Number: __________________________ Expiry Date: ___ / ___

Name on Card: _________________________ Amount: $ _________

Authorisation Signature: ___________________________

Please make your cheque/money order in favour of "State Mine Heritage Park & Railway".
Please do not send cash through the post under any circumstances.

Thank you for your donation.
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