For Office’s Use Dah Sing Maryknoll Convent School Platinum Visa Card MCS Ref: ______ Direct Debit Authorization Form PAYMENT ITEM Maryknoll Convent School Educational Trust Charity Donation I would like to support the aim of the Maryknoll Convent School Educational Trust by contributing a donation of HK$ _______________________________. INFORMATION OF DONOR Name (Block letter in English): Year in Form 5 (if applicable): Name of daughter(s) (if any): Class _____ (Year / ) E-Mail Address: Mobile: Address: CREDIT CARD ACCOUNT AND PAYMENT INFORMATION Credit Cardholder’s Name: Mr. Mrs. Ms. Relationship with Student(s): (The name printed on the Credit Card) Credit Card: DAH SING MARYKNOLL CONVENT SCHOOL PLATINUM VISA CARD Get 0.4% cash rebate Credit Card Account Number: 4 5 1 4 - 2 2 1 2 - - Card Issuing Bank: DAH SING BANK Card Expiry Date: M M / Y Y Signature of Credit Cardholder: Date: FOR OFFICE’S USE Date of Processing: Remarks: x (Same as Credit Card Account Signature) Declaration: 1. I hereby authorize Maryknoll Convent School Educational Trust to charge my Credit Card Account (“Credit Card Account”) for Maryknoll Charity Donation. 2. I agree to maintain sufficient credit limit in my Credit Card Account for the donation. 3. I hereby authorize the School, in accordance with the Personal Data (Privacy) Ordinance, to use and exchange any information for the purpose of autopay processing. 4. Completed form should be mailed / returned to: Maryknoll Convent School Educational Trust, Maryknoll Convent School, 5 Ho Tung Road, Kowloon, Attn: Ms Patricia Ling Receipt (if necessary) Name shown on the receipt (if different from above): Address (if different from above): (Please mark “Confidential” on the envelope. All donation over HK$100 are tax deductible. Should you have any queries, please contact Ms Patricia Ling, Trust Office Tel: 2337-2112 or email to firstname.lastname@example.org.