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Donation Form: Monthly Pledge

The document is a donation form for MERCY Malaysia, a non-profit medical relief organization. It requests contact information and allows donors to make either a monthly or one-time pledge by credit card or cheque. Donors can choose donation amounts starting from RM10 and are thanked for participating in MERCY Malaysia's humanitarian efforts.

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PerdanaMenteri
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141 views1 page

Donation Form: Monthly Pledge

The document is a donation form for MERCY Malaysia, a non-profit medical relief organization. It requests contact information and allows donors to make either a monthly or one-time pledge by credit card or cheque. Donors can choose donation amounts starting from RM10 and are thanked for participating in MERCY Malaysia's humanitarian efforts.

Uploaded by

PerdanaMenteri
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DONATION FORM

Name (Mr/Mrs/Ms): ______________________________________________________________________________________________________


Address: ____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________ Postcode: ______________________

Tel:(o) ____________________________________ (h): _________________________________(h/p): _______________________________________


Email: ____________________________________ Date of Birth: ______________________________

YES, I would like to be part of the humanitarian efforts organized by MERCY Malaysia through my donation.

MONTHLY PLEDGE
By making a monthly pledge through credit card autodebit* of
RM 10

RM 25

RM 50

RM 100

Others
RM _______________

(minimum donation of RM10.00)


*The specified amount of donation will be deducted monthly from your credit card(subject to your available credit limit) unless we are notified in writing
to do otherwise
Please debit my MasterCard/Visa (please delete where applicable)
Card Number: __________________________________________ Expiry Date: ________________________ Signature: ___________________________
Start from: ___________ / ______________ (Month/Year) to ______________ / ______________ (Month/Year)

ONE TIME PLEDGE


By making a one time donation of
RM 50

RM 100

RM 500

RM 1000

Others
RM _______________

(minimum donation of RM10.00)


Please debit my MasterCard/ Visa (please delete where applicable)
Card Number: _____________________________________

Expiry Date: ____________________ Signature: ___________________________

Or (Please fax or mail the bank-in slip together with this form)
Please forward form and cheques (if applicable) to:
Malaysian Medical Relief Society (Persatuan Bantuan Perubatan Malaysia) ( Reg No: 1155)
Level 2, Podium Block, City Point, Kompleks Dayabumi, Jalan Sultan Hishamuddin, 50050 Kuala Lumpur, Malaysia.
Fax No: 03-2272 3812

For Official Use:


Received By: _______________________________________________________________

Date Received: _____________________________________________________________

Receipt No: ________________________________________________________

Date Sent: _________________________________________________________

Vision:
MERCY Malaysia aspires to excel in medical relief, providing humanitarian
. services with the highest level of compassion, professionalism and care.
.

Mission:
MERCY Malaysia is a non-profit medical relief organization dedicated to providing
humanitarian services in crisis and non-crisis situations irrespective of race,
religion, culture and boundary.

Malaysian Medical Relief Society


(MERCY Malaysia)
[Reg No: 1155]
Level 2, Podium Block, City Point,
Kompleks Dayabumi, Jalan Sultan
Hishamuddin, 50050 Kuala Lumpur,
Malaysia
Tel: (603) 2273 3999
Fax:(603) 2272 3812
E-mail: info@mercy.org.my
Website: www.mercy.org.my

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