Fundraiser Payment Form Use this form to purchase tickets to a Variety SA fundraiser or fundraising initiative Fundraiser Payment Form First Name* Last Name* Mobile Number Name of fundraiser or fundraising initiative* eg. Bash Car 123 Raffle or Bash Car 01 Quiz NightCar / Bike Number or Team Name* If the fundraiser is for something other than a Motoring entrant please put N/ANumber of tickets* Total payment amount?* eg. 2x raffle tickets @ $10 = $20Do you wish to purchase tickets in a company / organisation name?* Yes No Name of company / organisation* Extra comments or information about your purchaseHow did you hear about this fundraiser?* I am happy to receive communication materials from Variety SA regarding upcoming news and events* Yes No PaymentTotal $ 0.00 Email Address for Receipt* Billing Address (optional) Street Address Address Line 2 City State Australian Capital TerritoryNorthern TerritoryNew South WalesQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia Postcode If you have any questions, please don't hesitate to contact us on (08) 8293 8744 or [email protected]Pay now for your Variety Fundraiser tickets.Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name CAPTCHA Δ
