Donation Form

PERSONAL PARTICULARS

Please tick:

¨  Personal                       ¨  Company

I require / do not require * a tax-exempt receipt.

Name as in NRIC (please print in BLOCK LETTERS) ¨  Dr     ¨  Mr     ¨  Ms     ¨  Mrs     ¨  Mdm

______________________________________________________________________________________

NRIC ________________________________         Date of Birth _____________________

Address _______________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Phone (HP) __________________    (Office) ____________________   (Home)______________________

Email  ____________________________________________________

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DONATION DETAILS

I wish to make a:

¨  One-time general donation of $ ____________________

¨  Regular donation of $ __________________________ per month / year*.

¨  Corporate donation of $ ____________________________

¨  Donation in kind (Please describe)

______________________________________________________________________________________.

Enclosed is a Cheque / Money / Postal Order No. _________________________ of $ __________________.

Please make all donations payable to Centre For Seniors.

Signature                                                                Date

___________________________                                  ______________________________

* Please delete accordingly.