MAKE A DONATION TODAY AND MAKE A REAL DIFFERENCE

Please complete this form and return it to:
Persatuan Mobiliti Selangor dan Kuala Lumpur
Letter Box #21, Room 9, 4th Floor
Wisma Sultan Salahuddin Abdul Aziz Shah
16 Lorong Utara A
46200 Petaling Jaya
Tel: 03-79577255

Title (Mr / Mrs / Ms / Dr / etc) .....................................................................................................

Name : ............................................................................................................................................

Address : ........................................................................................................................................

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Telephone No : ..............................................................................................................................

E-mail Address : ............................................................................................................................

Donations can be made by personal cheque or postal order in the name of “Persatuan Mobiliti Selangor dan Kuala Lumpur” or by transfer into our account:

Account No. 1045701154 (Al-Wadiah Account)
Southern Bank
933 Jalan 17/38
Section 17
46400 Petaling Jaya

Amount to be donated* (please tick)
 

	RM 10-100 -	Every RM10 ensures one disabled person can make an essential journey eg. to the hospital for rehabilitation or to a dialysis centre
	RM 100-500 -	Will pay for essential equipment , a wheelchair or safety belts
	RM 500 and above -	Will help us to expand the service to more remote areas in the Kelang Valley

*An Official Receipt shall be issued to all donors