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Septic Shock Clinical Research Fund

Donations of $2 or more to the Masonic Foundation,
on behalf of the SSCR Fund, are tax deductible.

Please accept my donation of $________ to the Masonic Foundation
on behalf of Lodge Foelsche's SSCR Fund.
Payment options (Please circle one)
  American Express
Card Number _______ _______ ________ _______
Expiry Date ___/___
Name on Card ________________________________
  Cheque (Payable to the Masonic Foundation)
Details for receipt
Name ________________________________
Address ________________________________
Suburb ________________________________
State __________________ Postcode _______

Please print this form and fill it out.
Then post it to:

The Masonic Foundation,
2/262 Grange Road,
Flinders Park, SA 5025.

Credit card donation details can be e-mailed to the Masonic Foundation.

© Lodge Foelsche, No 211 SA&NT.