Community Partnership Form

Full Name*

Business*

Email*

Phone Number*

Phone

Address*

Investment Option*

Platinum - Sponsorship of $15,000 P/A

Gold - Sponsorhip of $5,000 P/A

Silver - Sponsorship of $2,500 P/A

Subscription - $1,000 P/A for Three Years

Please Debit my card in the amount of: $*

Card Type

Visa

Mastercard

Amex

Card Number*

Expiry Date*

Cardholders Name:*

Cardholders Acknowledgement*

Please tick this box as your acknowledgement to funds being debited from your account.

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