Donation Test Page

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Notes:

Donations

Contribution Amount

$20 - $ 20.00

$50 - $ 50.00

$100 - $ 100.00

Other Amount

Other Amount $

Total Amount

I want to contribute this amount every

Name and Address

First Name *

Last Name *

Email *

Phone *

Street Address (Billing) *

City (Billing) *

Post Code (Billing) *

State (Billing) *

Country (Billing) *

Credit Card

Card Type

Card Number *

Security Code *

Expiration Date *

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Territory *

Post Code *

Contribution Rules

You are not a prohibited donor under Queensland electoral laws.
You are the true source of the funds.
You acknowledge that your donation, including your name and profession, will be publicly disclosed on the ECQ’s website if you donate $500 or more.

I confirm that the above statements are true and accurate. *