Miscellaneous Payment Form

Please charge to my credit/debit card:

The Australian$/US$ exchange rate is approximately: A$1.00 = US$ 0.78
The Australian$/Euro exchange rate is approximately: A$1.00 = EUR 0.65

Amount:
Currency:
For payment of the following (invoices, services, sponsorships, donations, please specify):

Name:
Title:
Company Name:
Address:

City/State/Postcode:
Country:
Telephone:
Fax:
Email:
Comments/instructions: