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DONATION FORM

Note: this is NOT an online form – it is designed to be printed out and filled in by hand.

If you prefer to make your donation by cheque rather than using Paypal online, please  click on the Print Friendly button located in the top right corner of the page.  If you wish to donate anonymously please make your donation by cash or bank cheque and leave the “Personal Details” section blank. Donations over $2 are tax deductible.

After clicking on the  Print Friendly button, select the  PDF option to turn the form into a PDF so you can download it onto your own computer or just select Print .  You can select which parts of the page to leave out,  such as this paragraph, by hovering your mouse over all the sections.  Print it out and fill in, then post with your cheque to:

Blepharospasm Australia Inc.
5 Fenton Place
Bouvard  WA 6211

Please make cheques payable to Blepharospasm Australia Inc.

I would like to make a donation of:

  • $5
  • $10
  • $20
  • $50
  • $100
  • $Other

Personal Details

  • Name:
  • Address:
  • Email:
  • Phone:
Blepharospasm Australia Inc. was registered as a charity in 2016 and was formerly the BEB Western Australian Support Group Inc.  Details can be found on the ACNC Register.
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Last updated: 11 May, 2017