Print out the donation application below

  • Send to your chosen organisation with your credit card details, cheque or money order
  • or Fax to your chosen organisation with your credit card details.

Organisation Contact Details
Appeal Name: Mirikai Residential Rehab Fund  
Organisation Name: Gold Coast Drug Council Inc.
Address: PO Box 2655
BURLEIGH MC QLD 4220
Fax: 07 55762512
Phone: 07 55354302

Donor Details
Title:   First Name:   Last Name    
Address:  
Suburb:  
State:   Postcode:  
Phone (H):   Phone (w):  
Fax:   Email:  

Payment Details
I would like to donate $ to Gold Coast Drug Council Inc.  
 
Enclosed is my cheque/money order
Please charge my credit card
 
Credit Card Details
Card Type: Visa Mastercard Bankcard AMEX
Card Number:
                                     
Expiry Date: ____/____
Cardholders Name:  
Signature:  
Date of Order: ____/____/____
 
Preferred Community Card for Australia



ourcommunity.com.au

Gold Coast Gives is an initiative of Gold Coast City Council and ourcommunity.com.au
for further details please contact Ms. Anna Rainbow