Online donations and New Member registration

All online donations and membership sign-ups are processed by DPS (a leading provider of Internet transaction processing in New Zealand and Australia). All payments go through a secure network and you will receive immediate confirmation when the transaction has been processed successfully.

Please take care to enter the correct information below:

	Personal Details
	Donation Type	Annual appeal Chair of Clinical Neurology General Donation Subscription Appeal
	Title	Please select... Mr Mrs Mr & Mrs Miss Ms Dr
	First Name
	Middle Initial(s)
	Last Name
	Postal Address
	Phone Number
	Alternative Phone Number
	Email Address
	Details of Donation and Member Registration
	Please enter the amount you wish to donate	$
	Please tick box if you would like to become a member*	$5 will be charged to your credit card.
	Renew Subscription	$5 will be charged to your credit card.
	*Only tick this box if you are not currently a member of the Neurological Foundation. If you tick the box you will be registered as a new member of the Foundation and an additional $5.00 will be charged to your credit card. For more information on what you will receive as a member, click here.
	*Please Note: We don't accept American Express