General Donation

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Last Name

Company/Practice Name

Would you like correspondence relating to your support to be addressed to you personally or your practice/company?

Me personallyMy practice/company

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Address 2

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Contact Details

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Telephone - Mobile

Donation

Donation amount (New Zealand Dollars)

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Credit Card (you will be directed to Payl Pal to pay online upon submitting this form)Internet Banking (you will receive bank details and payment instructions upon submitting this form)

Email Updates

We like to keep our supporters updated about the research we do and what is happening at the Centre and the College. If you would like to OPT OUT of receiving emails from us please indicate this below.

Please DO NOT send me email updates from the Centre for Chiropractic Research.
Please DO NOT send me email updates from the New Zealand College of Chiropractic.

Additional Comments