Dharma Friend SignupMembership DetailsSelect who the membership is for*I am an individualI have a partner / familySelect your level of membership*Dharma Friend - $35 per monthVajra Friend - $50+ per monthDharma Friend Amount*If you would like to donate more than $35 per month, please edit the amount belowPlease enter a value greater than or equal to 35.Vajra Friend Amount*If you would like to donate more than $50 per month, please edit the amount abovePlease enter a value greater than or equal to 50.Select your level of membership*Dharma Friend - $50 per monthVajra Friend - $65+ per monthDharma Friend Amount*If you would like to donate more than $50 per month, please edit the amount belowPlease enter a value greater than or equal to 50.Vajra Friend Amount*If you would like to donate more than $65 per month, please edit the amount abovePlease enter a value greater than or equal to 65.Total Monthly Amount Price: $ 0.00 Personal DetailsName* First Last Partner / Family Names*Please enter the name of your partner or the names of your family membersEmail* Phone*Address*We need your address to send you a tax receipt! Tax receipts are posted at the end of the financial year. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 GrenadinesSaint MartinSamoaSan 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 Payment OptionsPayment Method*Automatic Monthly Payment from your bank account (Preferred)Monthly Payments via Paypal (PayPal account or Credit Card). (Please note Paypal take a percentage of each payment)Cash / Cheque (6 months or 1 year’s payment to be paid in advance)Automatic Monthly PaymentDCI’s bank account is as follows: Name: Dorje Chang Institute Bank: ANZ Account Number: 06-0589-0167320-00 Please mark auto-pay “Dharma Friend” + "your name" and notify us when payment has been set up.Monthly Payments via PayPalWhen you press ‘Submit’ below you will be taken to PayPal to setup monthly payments using either a PayPal account or a credit card. To use a credit card press the ‘Pay using your debit or credit card’ link at the bottom of the page.Cash / ChequeHow many months do you want to pay for?*6 Months12 MonthsCash / Cheque Amount Price: $ 0.00 This iframe contains the logic required to handle Ajax powered Gravity Forms.