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Persatuan Kebajikan Orang Kurang Upaya Xi Le Er Malaysia (PPM-014-01-18032014) 1 Jln Bakawali 22 Taman Johor Jaya Johor Bahru 81100 Malaysia Tel : 07-3530139 Fax : 07-3530149 Email : xileer.org@gmail.com
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RECURRING PAYMENT DETAILS |
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Pay to Merchant |
Persatuan Kebajikan Orang Kurang Upaya Xi Le Er Malaysia |
Amount |
MYR 28.00 |
Number of Payments to be made |
12
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Frequency |
Monthly |
Product Description |
SPONSORSHIP PROGRAM |
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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 |
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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