AUSTRALIAN COALITION 99 COMMEMORATIVE PUBLICATION
Name:
....................................................
Address:
.....................................................
.....................................................
State: ...........................................
POSTCODE: ..............................
Contact phone no:
.....................................................
Contact fax no:
.....................................................
Email address: ....................................................
PAYMENT DETAILS Cost: $10.00 each x ......... copies & $2.50
P&H = TOTAL: $.......................................
Please charge my: Bankcard 1 Visa 1 Mastercard 1 Amex 1 Diners 1 Card
no: ..............................................
Amount:
....................................................
Expiry
Date:.................................. Cardholder's name:
......................................................
Signature: ......................................................
OR
please make your cheque payable to "Council on the Ageing
Australia" and send your order to: Council on the Ageing (Australia)
Level 2, 3 Bowen Crescent
Melbourne 3004 Victoria
Phone: (03) 9820 2655
Fax: (03) 9820 9886
Email:cota@cota.org.au