Date Of Birth
Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month:
January
February
March
April
May
June
July
August
September
October
November
December
Year:
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
State *
NSW
QLD
VIC
SA
WA
NT
ACT
TAS
OTH
If Other:
Country *
Afghanistan
Albania
Algeria
American
Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua
and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia
and Herzegovina
Botswana
Bouvet Island
Brazil
British
Indian OT
British
Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman
Islands
Central
African Rep.
Chad
Chile
China
Christmas
Island
Cocos Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican
Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial
Guinea
Eritrea
Estonia
Ethiopia
Falkland
Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French
Polynesia
French
S Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard
and McDonald Isles
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall
Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
FS of
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
N Mariana
Isles
Namibia
Nauru
Nepal
Netherlands
Netherlands
Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk
Island
Norway
Oman
Pakistan
Palau
Panama
Papua
New Guinea
Paraguay
Peru
Philippines
Pitcairn
Island
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
S.
Georgia S Sandwich Isls
Samoa
San Marino
Sao
Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Somalia
South Africa
Spain
Sri Lanka
St Helena
St
Kitts and Nevis
St Lucia
S
Pierre and Miquelon
St
Vincent and The Grenadines
Sudan
Suriname
Svalbard
and Jan Mayen Isles
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad
and Tobago
Tunisia
Turkey
Turkmenistan
Turks
and Caicos Isles
Tuvalu
US Minor
Isles
Uganda
Ukraine
United
Arab Emirates
United
Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin
Islands
Wallis
and Futuna Isles
Western
Sahara
Yemen
Yugoslavia
Former
Zaire
Zambia
Zimbabwe
Donation use
Unspecified
donation
Sight
Restoration and Blindness Prevention
Children's
Corrective Surgery
Education
Assistance
Assistance
to Desperately Ill Children
Equipment
Acquisition
Other
(with ability to type in project)