BTA Chapmans Peak Fund Fax Donation Page
Fax: +27(21) 790 7340

Please fill out the form using BLOCK LETTERS.

      First Name: ____________________      Surname: ____________________


          E-mail: ___________________


         Address: ____________________

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         Country: ____________________


             Tel: ____________________          Fax: ____________________


       Card Type: ____________________     Card No.: ____________________


Card Expiry Date: ____________________


Amount:     R50 []     R100 []     R200 []     R500 []     R1000 []


Signature: _________________________      Todays Date: ______________