Application Form
Please print this order form and post or fax it to us together with your international money order or cheque drawn from a bank with branches in Australia.

hereby I / we apply for a supporting membership for the year ____________ for

Name ............................................................................................………………...

Name .............................................................................................……………….

Postal Address .....................................................................................................

............................................................................... Postcode ............................

Phone (Work) .............................................. (Home) ...........................................

Email ................................................................................................................

Signature .................................................................. Date .................................

Project I / we want to support - ‚ general - ‚ special ...............................…

Supporting Member Application for one year	Number  Total A$
Adult A$ 75 ______ _________
Child/Student/Concession A$ 35 ______ _________
Family (3 or more) or company sponsorship A$ 100 ______ _________
Outside Australia - add A$10 to above prices ______ _________
SUPPORTING SHOP ITEMS
Every Day a Little Mirracle book by Kirsten Kuhnert A$22 (24.95 in shops) ______ _________
Postage & packing in Australia A$5, Overseas A$10 per item _________
I enclose a money order/bank cheque payable to 'dolphin aid Australia ', or please debit my credit card with the total shown here.	TOTAL in Australian $ _________
Card type (tick one):    ____ Bankcard    ____ Mastercard   ____ VISA
Card No. _  _  _  _  _   _  _  _  _    _  _  _  _    _  _  _  _
Expiry date _ _ / _ _
Cardholder's Name ............................................................................................... Postal Address ..................................................................................................... ............................................................................... Postcode ............................ Phone (Work) .............................................. (Home) ........................................... Email ................................................................................................................ Signature .................................................................. Date .................................

Send your order to dolphin aid Australia, PO Box 1340, Noosaville DC 4566, Australia,
or fax it to us (credit cards only) on +61 7 5471 1340.

DONATION ACCOUNT: dolphin aid Australia - BSB 034219 - Account 166158
Westpac Bank - 119 Poinciana Ave. - Tewantin - 4565 QLD - Australia
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