I would like to make a tax deductible donation to the THE BARIO PITE CLINIC in East Timor to assist in their work amongst the sick and poor.

Receipt required [  ]


Name: .....................................................................................................

Address: .................................................................................................

................................................................................................................

Contact phone: ........................................................................................

Email: ......................................................................................................


Payment method

[   ] Cheque: attached and made out to AFAP for Bario Pite Clinic


[   ] Credit card: Visa / Bankcard / Mastercard


Card no. ......../......../......../.........   Expiry ......../........


Cardholders name: ....................................................................................


Signature: .................................................................................................


Single donation [   ]  


Monthly debit from my credit card (as above) [   ]


Post to:

Australian Foundation for Peoples of Asia and the Pacific 
PO Box 12, 
Crows Nest NSW, 
Australia 1585.