Donation Form, Fragile Palm Leaves



Name: ____________________ E-mail: ______________________



Organization: ___________________________________________



Address: ________________________________________________



City: __________________ Postal Code: ___________________



Country: _________________________________________________



Telephone: ________________ Fax: ________________________



I wish to donate:(please tick the option)



Cheque payable to the Pali Text Society, Fragile Palm Leaves ____



Visa ____		MasterCard ____



Card no: __________________________________________



Expiry date: ______________________________________



Signature: ________________________________________