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Malaysian AIDS Foundation (PPAB032003)
No.12,Jalan 13/48A, The Boulevard Shop Office, Off Jalan Sentul Kuala Lumpur 51000
Malaysia
Tel : 0340474343 Fax : 0340474210
Email : hope@maf.org.my
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RECURRING PAYMENT DETAILS |
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| Pay to Merchant |
Malaysian AIDS Foundation |
| Amount |
MYR 10.00 |
| Number of Payments to be made |
Unlimited
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| Frequency |
Monthly |
| Product Description |
MAF H.O.P.E Donation Programme |
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| CREDIT CARD DETAILS |
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| First Payment Date |
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| Name On Card * |
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| CreditCard No. * |
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| CreditCard CVV * |
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| Card Expiry Date * |
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| CreditCard Issuer Country * |
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| CreditCard Issuer Bank * |
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| Identity Card No / Passport No * |
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| Card Holder Email * |
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| Card Holder Contact * |
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| Recurring Reference * |
Remark for your recurring payment, maximum 30 characters only. (eg. Donation, Payment for insurance plan, Bill payment)
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| Other Payment Details |
Description of purpose or other info related to your recurring payment, maximum 50 characters only. (eg. Monthly payment for my insurance plan)
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| PERSONAL DETAILS |
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Tick if Personal Information and Credit Card details are the same |
| Customer Name * |
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| Customer Email * |
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| Customer Phone No. * |
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| Customer Address * |
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| Customer Address Line 2 |
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| City * |
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| State/Province * |
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| ZipCode * |
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| Country* |
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