22/F, Pacific Plaza

410-418 Des Voeux Road West,

Sai Wan, Hong Kong
香港西環德輔道西 410-418 號
太平洋廣場 22 樓
TEL: (852) 2959 4229
FAX: (852) 2337 5442
E-mail: office@msf.org.hk
Website: http://www.msf.org.hk

取消每月捐款通知書
Termination of Monthly Donation

致 ：無國界醫生(香港)
To: Médecins Sans Frontières Hong Kong

本 人 決 定 由 _____________________________# (日期) 起取消下列每月捐款授權，謹此通知 ：

Please be informed that I would like to cancel the following monthly donation authorization to
MSF with effect from ___________________ # (Date):

Donation by:
直接付款授權 Direct Debit Authorization (DDA)
信用卡付款授權書 Credit Card

捐款人姓名
Donor Name : ______________________________________ _______ __

捐款者編號
Donor Number : __________________________________________ __ __

自動轉賬戶口號碼 / 信用卡號碼
Bank Account Number / Credit Card Number: _____________________ ___

聯絡電話
Contact Number : ________________________ ________ ____________________

捐款人簽署
Donor's Signature : _______________________ _________________ _____

日期
Date : __________________________________________ _____ _____

#由於銀行辦理取消手續需時，如欲由下月起開始取消每月捐款，自動轉賬捐款者需於本月廿
五號前通知我們，信用卡捐款者則需於下月七號前作出通知。

# Since the bank needs time to process a cancellation request, if you would like to
cancel your monthly donation with effect from next month, DDA donor needs to notify
us on or before 25th of the present month, credit card donor needs to notify us on or
before 7th of the next month.

MÉDECINS SANS FRONTIÈRES IS A PRIVATE, INTERNATIONAL, MEDICAL HUMANITARIAN ORGANISATION

無國界醫生是獨立的國際醫療人道組織