Cook Islands Form

$170 of $100,000 raised

$ Donation Amount:

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Personal Info

First Name *

Last Name

Email Address *

Billing Details

Country *

Address 1 *

Address 2

City *

Region *

Zip / Postal Code *

Donating by Online Bank Transfer or Bank Deposit:

Account name: Hope Channel NZ
Account number: 03-0175-0237739-001
Bank: Westpac

Please fill out the online banking fields or deposit slip memo as follows...

Particulars: Your name [no spaces e.g. JohnBrown]
Code:        Your phone number [no spaces e.g. 021033957 or 092501770]
Reference:   Cook Island

All contributions will be gratefully acknowledged and amounts over $5 are tax deductible.

Donation Total: $50.00

0800 694 673