HUMAN DEVELOPMENT FOUNDATION Mercy Centre Dona�on Please use this form when making dona�ons by credit card or bank transfer, and mail to the address at the bo�om of this page or fax back to (662) 671-7028. If you have special instruc�ons for us when making a dona�on, please let us know. Email us at [email protected] if you have any ques�ons. Thank you for your support. Name Address City Province/State Country Zip/Postal Code Email Phone Special Instruc�ons: For example – dona�ons made to specific programs or in memory of loved one, commemora�ons, etc. Please indicate here: Amount pledged: Payment op�ons (please check one): One-�me payment Repeat monthly Repeat yearly Method of payment (please check one): Bank Transfer Credit Card For bank transfer: Bank’s Name: TMBThanachart Bank Public Company Limited Branch: Vibulthani Tower Bank’s Address: Vibulthani Tower 1 ,3195/2 Rama 4 Rd., Savings Acct. # 958-2-04735-4 Khlong Ton, Khlong Toei, Bankgok 10110, Thailand. Swi� Code: TMBKTHBK Telephone: 02-661-5534-7 Account Name: Human Development Founda�on Note: Please inform us when making a wire transfer at [email protected] or by fax at (662) 671-7028 with your name, address, and dona�on amount. This informa�on will allows us to iden�fy and acknowledge your gi� with a receipt and le�er of thanks. For credit card payment: Visa MasterCard AmEx Name (on credit card) Credit Card Number Security Code (last three digits on the back of the card) Expiry Date Signature Human Development Founda�on 100 / 11 Kae-ha Klong Toey 4, Klong Toey Bangkok 10110, Thailand We stand together with the poor. Payment Instructions Form Dear Sirs, Please follow the detailed payment instruction below: Beneficiary bank (57A) TMBKTHBK TMBThanachart Bank Public Company Limited 3000 Phahon Yothin RD., Chompon, Chatuchak, Bangkok 10900 Thailand Account No. of Receiver (59) Branch เลขที�บัญชีผู้รับเงินโอน สาขา Name of Receiver (59) ชื�อผู้รับเงินโอน Address of Receiver (59) ที�อยู่ผู้รับเงินโอน Currency and Amount (32A) สกุลเงินและจํานวนเงิน Detail of payment (70) รายละเอียดการโอนเงิน Sender to Receiver information (72) /BNF/ รายละเอียดการโอนเงินสําหรับธนาคารผู้รับเงินโอน Name & address of Sender (50K) ชื�อและที�อยู่ผู้โอนเงิน (56A) Intermediary bank (Correspondent bank) CCY Intermediary bank Swift code CCY Intermediary bank Swift code AED STANDARD CHARTERED BANK, DUBAI SCBL AE AD IDR STANDARD CHARTERED BANK, JAKARTA, SCBL IDJ X AUD AUSTRALIA AND NEW ZEALAND ANZB AU 3M INDONESIA BANKING GROUP LIMIT INR STANDARD CHARTERED BANK, INDIA SCBL IN BB CAD BANK OF NEW YORK MELLON IRVT US 3N JPY MIZUHO BANK LTD MHCB JP JT CHF UBS AG, ZURICH UBSW CH ZH 80A BANK OF TOKYO-MITSUBISHI UFJ LTD BOTK JP JT CNH THE HONGKONG AND SHANGHAI BANKING HSBCHKHH HKH SUMITOMO MITSUI BANKING SMBC JP JT CORPORATION LIMITED CORPORATION, TOKYO CNY HSBC BANK (CHINA) CO LTD HSBCCNSH NOK NORDEA BANK NORGE ASA OSLO NDEA NO KK INDUSTRIAL and COMMERCIAL ICBK CN BJ NZD ANZ BANK NEW ZEALAND LIMITED ANZB NZ 22 058 BANK OF CHINA LTD. DKK DANSKE BANK A/S, COPENHAGEN DABA DK KK SEK NORDEA BANK STOCKHOLM NDEA SE SS EUR COMMERZBANK AG COBA DE FF SGD DBS BANK LTD, SINGAPORE DBSS SG SG DEUTSCHE BANK AG DEUT DE FF UNITED OVERSEAS BANK LIMITED, UOVB SG SG ING BELGIUM SA/NV, BRUSSELS BBRU BE BB 010 SINGAPORE STANDARD CHARTERED BANK, GERMANY SCBL DE FX USD BANK OF AMERICA N.A. BOFA US 3N BRANCH FRANKFURT THE BANK OF NEW YORK MELLON, NEW IRVT US 3N YORK UNICREDIT BANK AG HYV ED MM DEUTSCHE BANK TRUST COMPANY BKTR US 33 GBP STANDARD CHARTERED BANK, UK SCBL GB 2L HSBC BANK USA, N.A. MRMD US 33 HKD STANDARD CHARTERED BANK (HONG SCBL HK HH STANDARD CHARTERED BANK SCBL US 33 KONG) LIMITED WELLS FARGO BANK NA PNBP US 3N NYC JP MORGAN CHASE BANK CHAS US 33 This will enable us to received fund transfer faster on our account and avoid excessive foreign bank charges. Your Faithfully, ttb inward remittance 1/1 .