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					                                                                                                          You can fill in the form directly with Acrobat Reader 7 or above.
                                                                                                          Simply save the completed form and email to
                                                                                                          Or fax it to (852) 2893 3619 Or mail it to Plan International Hong Kong
                                                                                                          Rm 1104, Cameron Commercial Centre, 458 Hennessy Road,
                                                                                                          Causeway Bay.

                                   Yes, I want to support PLAN “Haiti Earthquake” donation!

                                                                               □One-off Donation
                                               Haiti earthquake relief and reconstruction efforts with the following amount:
                                               □HK$300        HK$500
                                                                 □          HK$1,000□      Other Amount: HK$__________
           Donations over HK$100 are tax deductible with our official receipts. We will send out consolidated receipt every April.

 Supporter Information
 Name in English:            Mr/
                          □ □ □     Mrs/ Miss/       □  Ms                                           Name in Chinese:

 Date of birth (dd/mm/yy):                                                                           ID / Passport No. (avoid record duplication):

 Contact No.:                                      Home/Office No:                                   E-mail.:


 Donation Method
 □By Credit Card:                          □  VISA         □   MasterCard              □  American Express                    □   Diners          □  Union Pay
       Cardholder’s name:                                                                            Credit Card Number:

       Authorized Signature:                                                                         Card Expiry Date (mm/yy):

     I hereby authorize Plan International Hong Kong Limited to charge my credit card account for the amount specified in a regular manner until further notice. I agree the validity
     of this agreement will continue before or after the expiry date of my credit card account. Transactions will normally be processed on the 15th of the month. Excluding the 1st transaction.

 □   By Crossed Cheque: Please send a crossed cheque made payable to “Plan International Hong Kong Ltd.” with this form.
       Cheque No.:_________________________

 □   By Bank Transfer: Please make a direct deposit into HSBC account no. 640-068292-838 and mail or fax the original bank receipt
       together with this form to us.

       Name of party to be credited (The Beneficiary)                       Bank No.                 Branch No.               Account No. to be credited
       Plan International Hong Kong Ltd.                                    004                      640                      068292838
       My/Our Bank and Branch name:                                         Bank No.                 Branch No.               Savings/Current Account No.

       Name of account holder(s) (in Block Letters):                        ID Number of account holder(s):                   Maximum Limit for each payment/month:
                                                                                                                              If blank, the debtor’s bank will set as unlimited. HK$

       My / Our Address as recorded on Statement/Passbook:

       Signature of Bank Account Holder:                                                                                              Date of Completing Form:

    For official use only:
       Debtor’s reference:                                                        For Bank use:                                         Signature Verified:
     1. I/We hereby authorize my/our above named Bank to effect transfers from my/our account to that of the above named beneficiary in accordance with such instructions as my/our Bank
     may receive from the beneficiary and/or its banker and/or its banker’s correspondent from time to time provided always that the amount of any one such transfer shall not exceed the limit
     indicated above. 2. I/We agree that my/our Bank shall not be obliged to ascertain whether or not notice of any such transfer or reversal notice has been given to me/us. 3. I/We jointly and
     severally accept full responsibility for any overdraft (or increase in existing overdraft) on my/our account which may arise as a result of any such transfer(s). 4. I/We agree that should there
     be insufficient funds in my/our account to meet any transfer hereby authorized, my/our Bank shall be entitled, in its discretion, not to effect such transfer in which event the Bank may make
     the usual charge and that it may cancel this authorization at any time on one week’s written notice. 5. This direct debit authorization shall have effect until further notice or until the expiry
     date written above (whichever shall first occur). I/We agree that if no transaction is performed on my/our account under such authorization for a continuous period of 30 months, my/our
     Bank reserves the right to cancel the direct debit arrangement without prior notice to me/us, even though the authorization has not expire or there is no expiry date for the authorization. 6.
     I/We agree that any notice of cancellation or variation of this authorization which I/We may give to my/our Bank shall be given at least two working days prior to the date on which such
     cancellation/variation is to take effect. Notes: 1. I/We confirm that my/our signature(s) onth  this application form is/are the same as that/those for the operation of my/our Saving/Current
     Account to be debited for the transfer. 2. Transaction will normally be processed on the 9 of the month. Excluding the 1st transaction.
 For PPS and Circle K / Vango Convenience Stores payment method please refer to Plan website for details.

 Donation Preference
 PLAN will choose a child who has waited the longest in a developing community unless you indicate your preference: ____________________
 My preferred language for communication with Plan is: English                □                 □               □
 Where did you hear about Plan (Please state): Internet__________________ TV Programme______________ Mailing_____________
                                                                  □                                              □                                                □
 □ Newspaper_________________ Referral _________________ Outdoor Advertising_______________ Others_________________
                                                   □                                            □                                                         □
The personal information will be kept confidential and used for donation, supporter service and communication purposes only. It will not be sold, traded or rented to
any other organisation. If you do not wish to receive future mailings from Plan or would like to have access and correction to your personal data, please contact us.
                             Hotline: 3405 5305                    E-mail:                             Website:

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