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Total Mobility Annual Renewal
I would like to renew my Total Mobility Card
Amount
$35.00
Other amount
$
$35.00
Other
$
Total amount
$
Pay/Donate method
*
Credit Card
Direct Credit
Make deposit to account
02-1257-0062965-000
Pay processing fee
$
Message with your donation:
Billing Details
Persons name
First name
Last name
Organisation name
if applicable
Persons address
Address line 1
Address line 2
Address line 3
Address line 4
Town/Suburb
City
Postcode/Zip
Email address
Cell phone
Home phone
THANK YOU FOR YOUR SUPPORT
MS and Parkinson’s Canterbury Charitable Trust
70 Langdons Road
Papanui, Christchurch 8053
www.ms-pd.org.nz
Please check the highlighted fields
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