ISISA Fax Donation Page

ISISA is a registered charity organisation (Registration No. 96/07685/08)

Tel: +27 21 790-7182

Fax (1): +27 21 790-7184
Fax (2): +27 21 52-3309

Angola Refugee Crisis

Please fill out the form using BLOCK LETTERS.

      First Name: ____________________      Surname: ____________________


          E-mail: ___________________


         Address: ____________________

                  ____________________

                  ____________________


     Postal Code: ____________________


         Country: ____________________


             Tel: ____________________          Fax: ____________________


       Card Type: ____________________     Card No.: ____________________


Card Expiry Date: ____________________


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


Signature: _________________________      Todays Date: ______________