The Victims of Chernobyl membership, donation and information form

Post to:
Victims of Chernobyl
GPO Box 1727P
Melbourne 3001

Name:
 

Address:
 

Phone:
 

E-Mail Address:
 

Please tick any or all of the below.

I would like to become a member of the fund $20.00 per year
   
I wish to subscribe to the newsletter $16.00 per year
   
I enclose a donation to assist in the plight of the victims of chernobyl $
 
   
I would like information on hosting a child.
   
Please make cheques payable to The Victims of Chernobyl National Relief Fund Inc.