Donation Form printable pdf download

Donation Form

Please send the form to:

Fax #: +966 2 6976051, PO Box 53203, Jeddah 21583

Name: _____________________________

Telephone: Home: ____________

Office: _____________Fax: _______________

Mobile: ___________________ E-mail:

________________________________________

Address: ____________________________________

PO Box: ________

Postal Code: _______

City: ________

Country: ______

_____________________________________________________________________

Please tick [√ ] to specify the type of donation:

[ ] Donation for Zakat

[ ] “Arzaq” Donation for Patients

[ ] Donation for Medical Services (equipment or medical requirements)

[ ] Donation for Social Services (health awareness or entertainment for patients ….)

[ ] Donation for Home Healthcare Centers.

[ ] Other Donation ……………

[ ] Donation for the Guest House (Cancer

Patients)

_____________________________________________________________________

Do you want to have your donation recorded in your name? [ ]

Do you want your donation to be recorded in the name of a “philanthropist”?

Mode of Donation:

[ ] In Cash

[ ] By Cheque

[ ] By Transfer

Type of Donation: [ ] Money Donation

Amount:

[ ] Donation in kind

_____________________________________________________________________

In case you desire to make a donation under a cheque, please make it in the name of

the National Home Health Care Foundation, Western Province, or deposit it in the

Account No. 2810700001 at SAMBA Financial Group.

Donation Form