Donation Name of Individual/ Organisation(*) Please input full name IC No / Company. No(*) Invalid Input Occupation (if applicable) Invalid Input Address(*) Please input address. Email(*) Please input email. Home Phone Invalid Input Office Phone Invalid Input H/P Invalid Input __________________________________________________________________________________________________________________________________________________ PAYMENT DETAILS : Account Name : Persatuan Kebajikan Agape Melaka Account No : 039-201-200251-4 Bank Name : AmBank Berhad __________________________________________________________________________________________________________________________________________________ PAYMENT METHOD : Bank name Invalid Input Cheque/transaction no Invalid Input Amount Invalid Input in MYR __________________________________________________________________________________________________________________________________________________ I will bank in directlyInvalid Input Please send completed form and bank-in slip via fax/email: +6063341121/agapecaremlk@gmail.com __________________________________________________________________________________________________________________________________________________ I will post a chequeInvalid Input Please post complete form and cheque to AgapeCARE Society609, Taman Sri Indah, Kampong 8, 75200 Melaka, Malaysia. __________________________________________________________________________________________________________________________________________________ Please send me a tax-exemption receiptInvalid Input *ALL DONATIONS TO AGAPECARE ARE TAX-EXEMPT __________________________________________________________________________________________________________________________________________________ Please send me newsletters/more information on your workInvalid Input Enter the numbers to eliminate spam: RefreshInvalid Input
