Please print this form and send to:

I would like to make a donation to Chatterbox of

[___] £10       [_ _] £20       [___] £50        [___]  £ other  £____________

Name         __________________________________________________________

Address     __________________________________________________________

                   __________________________________________________________

Post Code  _____________       Telephone Number _________________________

I enclose a cheque or postal order payable to Chatterbox

Signature ________________________       Date ____/____/_____

I would like Chatterbox to reclaim tax from my donation    [______]