1. Donation Details

  2. Title *
    Invalid Input
    eg. Mr, Mrs, Ms
  3. First Name *
    Please let us know your first name.
  4. Last Name *
    Please let us know your last name.
  5. Spouse First Name
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  6. Spouse Last Name
    Invalid Input
  7. Address *
    Please let us know your address.
  8. Suburb or Town *
    Please let us know your suburb.
  9. Postcode *
    Please let us know your postcode.
  10. State *
    Invalid Input
  11. Phone Number *
    Please let us know your contact phone number.
  12. Email *
    Please enter a valid email address.
  13. Missionary or Ministry Name *
    Please let us know your Missionary or Ministry name.
  14. Missionary or Ministry Number *
    Please let us know your Missionary or Ministry number.
    (7-digit numbers only)
  15. Donation Amount

  16. Amount *
    Please let us know what you would like to donate in dollars (in numbers).
    (Full numbers only - do not use $ signs, full stops or cents)
  17. Donation Type *
    Please let us know your preferred donation type.
  18. Giving Frequency *
    Please let us know your preferred giving frequency.
  19. Giving Start Date *
    Please select a date for your first payment.
    (Must be AFTER today's date)
  20. End After *
    Please let us know your preferred giving frequency.
  21. Number of Payments *
    Invalid Input
  22. Giving End Date *
    Invalid Input
  23. Payment Method *
    Please let us know your preferred donation method.
  24. Last 4 numbers of your Credit Card *
    Please let us know the last 4 numbers of your Credit Card.
    (For our crosscheck purposes only. You will be asked to complete your full banking details on the BPoint banking form on the next page).
  25. Last 4 numbers of your Bank Account *
    Please let us know the last 4 numbers of your Bank Account.
    (For our crosscheck purposes only. You will be asked to complete your full banking details on the BPoint banking form on the next page).
  26. I/We hereby authorise Power to Change to increase the regular partnership amount by 5% annually. *
    Please let us know if you authorise CCCA to increase the regular partnership amount by 5% annually.

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