HealthEx International Pledge Form

Donation Pledge Form

Donor/Organisation name*

Address*

Postal code*

Phone no.*

Area CodePhone Number

E mail address*

example@example.com

By signing below, I/we are committing to the following donation/pledge to HealthEx International.

Pledge amount (SGD)*

To be used for: (Check one or multiple)*

HealthEx general fund - running costs, financial aid for participantsProject Phetchabun (Thailand, partnership with RADION International)Project Bottrong (Cambodia, partnership with Build Your Future Today)Project Cebu (Philippines, partnership with Rise Above)

If you have selected more than one of the above, please specify how much you would like to give to each

Please check one*

I am fulfilling the entire pledge at this timeI would like to set up a standing instruction for monthly installments forOther

If you have selected monthly installments, please fill in the blanks below:

I would like to set up a standing instruction for monthly installments of
SGD$ (amount) over (no. of) months.

Monthly installments will be scheduled for the (date) of every month.

Payment intructions

Bank: POSB

Account number: 271-614477-1

Signature*

Full name of donor/representative of organisation*

Date*

Thank you for your kind donation to HealthEx International. Your support is vital in raising up the next generation of healthcare professionals, serving the underserved in Southeast Asia.

HealthEx International is a non-governmental society (UEN T09SS0176L). For more information, please email president@healthexinternational.org