Authorization Form En

For your convenience, Wild At Heart now provides the option of making contributions by credit card. Just fill out the "automatic debit authorization form" below, authorizing the Wild at Heart Legal Defense Association, Taiwan to make a debit/debits from your designated credit card, to allow for continuing contributions to environmental issues of special concern.

Please print and fill out: Wild at Heart Legal Defense Association, Taiwan Receipt □Individual recipient: □Company Phone: Home:

Office:

Address: Date of birth: Notes:

Automatic Debit Authorization Form National ID No. GUI: Mobile:

E-mail:

(For convenient contact and quick delivery of important notifications)

1. This information is necessary in order to issue and deliver receipts. 2. If the recipient of the receipt is different from the cardholder making the contribution, please specify your relationship with the cardholder. 3. Please note whether your credit card's period of validity covers the period of contributions!

【Credit Card Information】 】(Please print) Card type: Card No.: Issuing bank:

□U Card Expiration ＿＿＿＿─＿＿＿＿─＿＿＿＿─＿＿＿＿ date: Card security code (3-digit Signature: □VISA

□MASTER CARD □JCB

number on reverse side):

____ mn _______yr

(Must be identical to signature on card's reverse side)

□Single contribution amount: NT$ . □Fixed monthly contribution amount (in NT$): □300 □500 □600 □800 □1000 □Other amount: NT$ . Period for fixed monthly contributions: Start: __yr mn; end: __yr Or: □Until notice of cancellation

mn

Siganture: Date:

__yr

mn

day

Purpose: □Indo Pacific Humpback Dolphin ("Matsu fish") research & conservation □Authorize Wild at Heart Legal Defense Association to allocate contribution for specific purposes Please fax the above information to: 02-2382-5810, or E-mail: [email protected], or mail to: Wild at Heart Legal Defense Association, Taiwan, 12F, 86 Chongcing South Road Sec. 1, Taipei, Taiwan 10045.

【Please note:】

※Wild at Heart will automatically debit your card from this date until such time as we receive notice of your cancellation or change in authorization. ※Receipts issued by Wild at Heart may, in accordance with the law, be deducted or reported as expenses for the current year on your consolidated income tax return. ※Receipts for fixed monthly contributions will be issued together by mail at year's end for the convenience of your records and tax statements. ※Upon receipt, Wild at Heart will confirm the information you have submitted by phone or e-mail. ※Wild at Heart's web address is http://www.wildatheart.org.tw; for the Matsu Fish Conservation Union, http://twsousa.blogspot.com. Please visit these sites to find the latest information on environmental issues in Taiwan and efforts to save the Indo Pacific Humpback Dolphin, or Matsu fish. Please call 02-23825789 to inquire about any questions you may have.

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