願 望 成 真 基 金

捐 款 表 格 DONATION FORM

請將填妥的表格寄回或傳真至「願望成真基金」辦事處

Please return the completed form by post or fax to Make-A-Wish Foundation® of Hong Kong

謹付上下列金額購買願望熊，善款將幫助香港患重病兒童達成願望以懷念李卓思小朋友之用：

I would like to purchase Wish Bear(s) at $200 each and grant wish(es) to seriously ill children in fond memory of Chelsea Lee:

□HK$200   □HK$400   □HK$600   □HK$800   □HK$1,000   □HK$              

   1 bear         2 bears      3 bears      4 bears      5 bears       ___bears

捐款方法Donation Methods:

□   支票號碼 Cheque #                           支票抬頭：「願望成真基金有限公司」

□  Donation only, please do not send me bear(s). 只作捐款之用，不需要願望熊。

Payable to: Make-A-Wish Foundation of Hong Kong Limited

□   直接存款 Direct Transfer

     銀行Bank:                     HSBC     香 港 上 海 匯 豐 銀 行

戶口號碼 A/C No.：         042-1-056-243

請將入數紙寄回本會或傳真至2856 9600.  Please fax your payment slip to 2856 9600

□   信用卡 Credit Card

□Master           □Visa             □American Express*   *豁免手續費Service charge is exempted

        持卡人姓名 Cardholder’s Name

        信用卡號碼 Card #

 

持卡人簽署 Signature                                                                                              

有效期至Expiry Date                                                        月MM/                             年YY

(如以下資料與持卡人或支票上署名不同，請註明．Please specify name on receipt if different from above.)

願望熊主人姓名Wish Bear Owner:                                                                                                   

願望熊送遞地址Wish Bear(s) Delivery Address: