Donation Form

If you wish to make a donation, please print this form, complete it and mail to:

The Florey Medical Research Fund
Medical Foundation
The University of Adelaide SA 5005

Donation from

M ________________________________________________________________

Address ___________________________________________________________

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___________________________________________ Postcode _______________

Telephone _______________________________

Amount $ ________________________________

If this gift is IN MEMORY, please supply name of deceased and next-of-kin details/address for acknowledgement 

____________________________________________________________________

____________________________________________________________________

If you would like your gift applied to a particular area of RESEARCH please specify

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PLEASE TICK  IF YOU WOULD LIKE TO RECEIVE INFORMATION ON BEQUESTS SUPPORTING OUR WORK 

Donations are tax-deductable and receipts will be sent.