Your name_____________________________________________________
Address_______________________________________________________
Postcode________Telephone
(Work)____________(Home)______________
E-mail:________________________________________________________
1. Name of Deceased ____________________________________________
*Application Number: ____________________________________________
2. Name of Deceased ____________________________________________
*Application Number: ____________________________________________
3. Name of Deceased ____________________________________________
*Application Number: ____________________________________________
4. Name of Deceased ____________________________________________
*Application Number: ____________________________________________
(* mandatory field –
please look up the name on our search
facility to ensure we are advised of the
correct person)
Total number of photos required:
_____
Total payment owing:
___ digital photos (by e-mail)
@ AUD$28.60 each AUD$_____
___ digital photos (posted
on CD) @ AUD$40.70 each AUD$_____
___ each additional photo
in any format @ AUD$11.00 each AUD$_____
All prices above are inclusive
of GST.
Method of payment:
Cheque__________ Money Order_____________
Credit card:
Name of cardholder:
Bank or financial institution:
Credit card number:
Expiry Date:
If you would like to use this
photo as part of an Online Memorial, please
visit our Memories
e-ternal website at www.memories-e-ternal.com.
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