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Donation Amount: NT$
Purpose of Donation:
Donor Name:
Address:


Phone number: Day Time: - Ext Mobile:
E-Mail:
Way to send a receipt: End of the year Do not send a receipt  (If you choose this item, don't have to fill out the following columns)

Receipts title:   (If there are two or more donors who need receipts, make notes in the remarks column)
Mailing address:

Same as above address  (If you choose this item, do not fill out the following columns)

Address:

Notes:
Please fill up the following page.