Stella Langford Wing

About the donor

Donation by:

Individual
Company
Trust or other similar fund
Other funding entity type

Donor name*

Company Name*

Trust or fund name*

Name of other funding entity type*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I wish to be named as a supporter

Yes
No

^Yes' indicates that you are happy to be acknowledged (first name and surname) for your donation in our publications. 'No' indicates that you wish to remain anonymous. If neither 'Yes' nor 'No' is selected a 'Yes' response is assumed.

The company is to be acknowledged

Yes
No

^Yes' indicates that the company name will be acknowledged for the donation in our publications. 'No' indicates that the company name will not be given. If neither 'Yes' nor 'No' is selected a 'Yes' response is assumed.

The funding entity is to be acknowledged

Yes
No

^Yes' indicates that the name of the funding entity will be acknowledged for the donation in our publications. 'No' indicates that the funding entity will not be named. If neither 'Yes' nor 'No' is selected a 'Yes' response is assumed.

Equipment provided

Safe

Ensuite

Alarm Clock

Laundry

Couch

Kitchenette

Television

Room Type

Contained Deluxe Apartment - Large

Contained Deluxe Apartment - Medium

Amount

Your Details

Payment

About the person completing this form

About the donation

About the donor

Payment of the donation

Please direct cheque to The Graduate Union of The University of Melbourne Inc.