Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Credit Card Authorisation *

I wish to contribute via monthly credit cared deductions. I authorise the Catholic Parish of St. Michael, Lane Cove to debit my credit card on the 15th day of each month until further notice.

Cancellations *

I understand that this authority may be cancelled in writing by me at any time.