One Off Gift Amount to donate (£)* Title*MrMrsMissMsDrFirst name*Last name*Email Address 1*Address 2City / Town*PostcodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Telephone (optional - in case of queries about your donation)Please tell us your reason for supporting Myton todayGift Aid DeclarationIf you are a UK tax payer, you can boost your donation by 25p for every £1 you give to The Myton Hospices by allowing us to claim Gift Aid. This means that we can claim back the tax you have paid on the money you have donated to us.Please treat as Gift Aid donations all qualifying gifts of money (PLEASE TICK relevant box) From 6th April 2012 //and any I may make in the future, until I notify you otherwise For my latest donation// and any I may make in the future, until I notify you otherwise.I am a UK tax payer and confirm I will pay an amount of income tax for each year that is at least equal to the amount of Gift Aid that all charities that I donate to will reclaim on my behalf. If I pay less Income Tax/Capital Gains Tax in any tax year than the amount claimed on my donations, it will be my responsibility to pay any difference back. If you are NOT a UK taxpayer or do not wish to Gift Aid your donations, please tick this box and return this form to us – it will help us keep our records up to date and ensure we don’t ask you again. DATA PROTECTION The Myton Hospices value your support and promises to respect your privacy. The data we gather and hold is managed in accordance with the Data Protection Act (1998). We will not disclose, or share personal details with any third party organisations. If you would like to receive information from The Myton Hospices please let us know by ticking this box.