SA RED CROSS AIR MERCY SERVICES CHANGING LIVES! SAVING LIVES!

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Either complete form below and SUBMIT ONLINE or print out, complete and then fax to us: +27 21 934 8700
Section 1 - Please complete fully:
Title
Name
Address
Postcode
Telephone
Fax
E-mail
Signed
I require a section 18A tax receipt please.
Date
Section 2 - Please complete if you are making a one-off donation (please tick appropriate boxes)
I would like to make a one-off donation of	R (figures) R (words)
by cheque (enclosed)
by credit card	(please complete the following details)
Name of card holder
Credit card No
CVC Number last 3 digits on back
Expiry	/
Section 3 - Please complete if you wish to make a regular donation by stop order
I would like to make a donation of	R (figures) R (words)
Commencing	(date of 1st payment)
and thereafter every	week/month/year until further notice.
Please pay to SA Red Cross Air Mercy Service Trust Bank: Absa, Parow Account Number: 01133820210 Branch Code:502110
From (Account Name)
Account Number
Branch Code
Bank Name
I wish to support the following base: All bases Cape Town Durban Kimberley
OUR BANK DETAILS Bank Account Name: SA Red Cross Air Mercy Service Trust Bank: Absa, Parow Account Number: 01133820210 Branch Code:502110 If you make a bank deposit or electronic transfer, kindly fax a copy of the transmission slip to us at (021) 934-8700, for our records.