---- ---- ---- ---- ---- ---- ---- ---- " ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ----

Cambodia Support Group – Monthly pre-authorized withdrawal form and order form

Donation address: 135 Thompson Street, Kimberley BC Canada V1A 1T9 Ph/Fax 250-427-2159 csg@cyberlink.bc.ca

The monthly contribution Name _______________________________________ Phone (_____) ______________

form may be used for Fax (_____) _____________ e-mail _________________________________________

regular donations to Address _________________________________________________________________

support CSG projects. _____________________________________________ Postal Code________________

Please include a Organization (if applicable) ________________________________________________

signed, void cheque or o Post-dated cheques - please include a supply of them with this form

printout from your bank o Automatic withdrawal $ ______ monthly - Start date: y_____/m_____/d_____

for automatic withdrawals. o Use as needed or Which project(s) ________________________________________

Total Enclosed: $ ________ Thank you for your support. Tax receipts will be issued for all donations.

o Large-print newsletters o Newsletters by e-mail

---- ---- ---- ---- ---- ---- ---- ---- " ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- ----

Cambodia Support Group - Membership/Donation Form

Donation address: 135 Thompson Street, Kimberley BC Canada V1A 1T9 Ph/Fax 250-427-2159 csg@cyberlink.bc.ca

The annual membership Name _______________________________________ Phone (_____) ______________

fee is set at CDN$15.00. Fax (_____) _____________ e-mail _________________________________________

For all donations above Address _________________________________________________________________

that amount, the first _____________________________________________ Postal Code________________

$15.00 will be set as a Organization (if applicable) ________________________________________________

membership fee. The full o Membership $15.00 o New Membership o Renewal

amount is tax-creditable Date _____________ Membership is valid for one year from date of receipt.

for Canadian donors. o Donation $ ________ or o Monthly by post-dated cheque (see form p.5)

Use o as needed or for which project(s) ___________________________________________

Total Enclosed: $ __________ Thank you for your support. Tax receipts will be issued for all donations.