(Retreat Deposit form)

< (Retreat Deposit form)

Retreat Deposit / Application Form

Your deposit can be paid for by clicking on the 'Add to Cart' button and then submitting this form without credit card details. (Credit Card Details will be collected by the shopping cart).
or
You can print this form and send with your deposit or card details to the address below.

First Name:

Last Name:

Street Name & No. / PO Box No.:

Suburb:

State:

Post Code:

Telephone:

Mobile Number:

Email:

Deposit Amount:

Payment Method:

Card Number:

Expiry Date:

Name on Card:

Signature:

I wish to participate in the Retreat.

My second choice Retreat is:

I am prepared to share a room: Yes / No

Comments:

Send this form to: The White Eagle Lodge
PO Box 225
MALENY 4552
Phone: 07 5494 4397 Fax: 07 5494 4169