Medecins Sans Frontieres Hong Kong – MONTHLY DONATION FORM
無國界醫生香港辦事處 – 每月捐款表格
Please complete and print this form, and then send to us by post or by fax (852) 2304 6081
Address: 22/F, Pacific Plaza, 410 - 418 Des Voeux Road West, Hong Kong
請填妥後列印此表格, 並郵寄或傳真至 (852) 2304 6081
地址：香港德輔道西410-418號太平洋廣場22樓
Donor Personal Information 捐款者個人資料
Title
稱呼		 Donor No. (If applicable)
捐款者編號(如適用)
Last Name
姓
 First Name
名
Other Name/
Company Name
別名/公司名稱
Chinese Name
中文名稱
ID Card No.
身分證號碼
 (Optional, for avoiding duplication of records)
(如填寫可避免資料重複)
Mailing Address
郵寄地址
Telephone Number
電話號碼
(Residential 家居) (Office 辦公室)
(Mobile 手提)    
E-mail 電郵  
Donation Details 捐款資料
Monthly Donation in HK 每月捐助港幣 $
American Express (Service Charge Waived)
美國運通信用卡(可豁免手續費)		 Diners Club
 大來
Visa / Master
萬事達
Card No. 信用卡號碼
Expiry Date 信用卡有效日期 (MM 月/ YY 年)
Card Holder's Name 持卡人姓名
   
   
   
Signature 簽名: __________________________
 
My authorization for Medecins Sans Frontieres Hong Kong to debit the specified amount from my credit card account monthly will continue after the expiry date of the credit card and with the issuance of a new card until further notice.
本人授權無國界醫生香港辦事處每月由本人之信用卡戶口轉賬上述指定金額。此授權在本人信用卡之有效期過後及獲發新卡後仍繼續生效，直至另行通知。
   
Remarks 備註
  
(NET08/CCRDON)
Note: We shall use your personal data for issuing receipts, fostering communications, raising funds and conducting donor survey for MSF. We may furnish your data on a strictly confidential basis to third parties, who provide services to us in relation thereto.
注意事項：無國界醫生將運用你的個人資料作發出捐款收據､通訊､籌募本會經費及收集意見之用途。我們可能將有關資料提供予第三者服務供應人進行以上有關運作，但所有資料均絕對保密。