MAKNA (Majlis Kanser Nasional), BG 03A & 05, Ground Floor, Megan Ambassy, 225 Jalan Ampang,

50450 Kuala Lumpur, Malaysia

Tel: 03-2162 9178 Fax: 03-2162 9203 E-mail: makna@makna.org.my URL: www.makna.org.my

DONOR FORM

Donor Details: Date: _____________________

Title : Mr Mrs Miss Race : Malay Indian Chinese Others Name (as per NRIC) : _________________________________________________________________________________ (BLOCK LETTERS) NRIC old : _______________________________ NRIC New : _________________________________ Passport No : _______________________________ Business Reg No. : __________________________________ Address : ________________________________________________________________________________________________ (BLOCK LETTERS)

________________________________________________________________________________________________ State: __________________________________________________ Postcode: _________________________ Contact No : _____________________________________ (Hs) ______________________________________(Off) : _____________________________________ (HP) _____________________________________ (Fax) E-mail : ________________________________________________________________________________________ Preferred Mail : E-Mail Postal Mail (Select your preferred mode of communication) Credit Card No : ____________________________________________ Issuing Bank : _______________________________ Expiry Date : ____________________ Security Number (3 numbers from reverse side of the card) __________ Account Holder Name : _________________________________________________________________________________

Account Type : SOLE ACCOUNT ONLY Savings Current Account No : MAYBANK___________________________________ RHB __________________________________ I hereby authorize MBB/RHB to debit my account above after receiving instructions from MAKNA and I agree to pay the nominal of RM1.00 per successful transaction to the bank for the provision of the Autodebit Services by debiting my account where the donation is made from. Dengan ini saya membenarkan MBB/RHB untuk mendebit akaun say sama seperti yang dinyatakan di atas berikutan arahan yang diterima daripada MAKNA dan saya juga setuju untuk membayar RM1.00 daripada akaun saya kepada bank berkenaan bagi setiap transaksi yang Berjaya dilakukan sebagai caj perkhidmatan debit langsung ini.

Frequency (please select): One Time Donation : RM ________________ Monthly (RM38 / RM58) : RM________________ 6 Monthly (RM228 / RM348) : RM________________ ___________________________________ via MAKNA website Donor Signature

MAKNA

AUTO DEBIT AUTHORISATION (BANK)

CREDIT CARD AUTHORISATION

PREFERRED AMOUNT OF DONATION

Attention this Donor Form to Miss NORLI

E-mail: norli@makna.org.my