國立成功大學接受捐款表
NCKU Donation Acceptance Form
※※※※若捐贈有價證卷或實物者，請改填寫國立成功大學接受實物捐贈表※※※※
基本資料
Donor Information
֑Τ
/
ఊЗeዚ
Name/Organization
Ԓʱᗇο
/
୕ɓᇜ
IDNo./Tax IDNo.
Ԓʱ
Identity
ࣧʾd
ӻ
ॴ
ᔖࡰʈ
ኪ͛
ڗ
ٟึɛɻ
Άุྠ
Չ̴
ཥ༑
/
˓ዚ
Telephone/Mobie
ෂॆ
Fax
ஷৃήѧ
Address
ཥɿ
ڦ
ᇌ
E-mail
捐款資料
Donation Information
࣏ಛ
ږ
ᕘ
DonationAmount
อၽ࿆
NewTaiwanDollar
ʩ
Dollars
̮࿆
ForeignCurrency
࿆й
Currency
ʩ
Dollars
࣏ಛ͜
Donation Specification
ʔܸ֛
Non-Specified
τːఱኪп˙ࣩ
Financially-at-Ease Program for NCKUStudents
Չ˼ܸ֛͜
Specified
ቱಛᓥͭ͟ϓ̌ɽኪ୕ᘪԴ͜
Balance to be used byNCKU
ቱಛᓥᒔ࣏ᗍ٫
Balance to be returned to the donor
捐款方式
Donation Method
ତ
ږ
Cash
˕ୃ˕ୃᇁ
Cheque
Cheque No.
±˕ୃ
ױ
᎘jͭϓ̌ɽኪԨຫ˟
ߠ
ࣣᔷᜫ
Pleasemake check payable toNCKU.
ිಛ
Wire Transfer
ሗ
ڝ
ᗇ˖
Please attach a copy of the receipt
ATM
ᔷ੮
webATM
ᔷ੮
ვБිಛ
Bank Transfer
±ვБj͗ʆვБ
ږ
ശʱБ˾ᇁj
808
d˒Τjͭϓ̌ɽኪ
410
ਖ਼˒d੮j
1067-951-000001
ACH
ᔷ੮֛ಂ࣏ಛ
±ν૧Դ͜
ACH
ᔷ੮֛ಂ࣏ಛdሗၾҢ
ࡁ
ᑌᖩdਗ਼
މ
આԶ
ࡈ
йਕf
א
Ї͉࣏ࣧᗍၣ१ɨ༱બᛆࣣ
ڦ
̔͜ෂॆ࣏ಛ
Credit Card By Fax
ሗ෬
ڦ
̔͜
ڌ
ࣸԨෂॆՑ
06-200-2690
Please fill in the formand fax to:886-6-200-2690
ܵ̔ɛ֑Τ
Name on Card
Ϟࣖಂࠢ
Expiration
Гʩ
20
ccccϋcccc˜
ccc
cccc
Y
c
ccc
M
ڦ
̔͜
Card Number
-
-
-
ߠ
ࠦ͋ɧᇁ
ڦ
̔͜й
Card Type
VISA JCB MasterCard
ܵ̔ɛፋᖦცၾ
ڦ
̔͜ɪᖦΤɓ
ߧ
Signature
Signature as it appears on card used
೯̔ვБ
Issuing Bank
ვБ
開立收據
Receipt
ࠅ
Yes
ccc
ʔ
ࠅ
No
芳名錄
Disclosure Agreement
Νจਗ਼֑Τe࣏ಛ
ږ
ᕘ̊೮͉ࣧᗫၣ१
א
̊
ي
ɪf
I agree to publicize the contribution information
name and amount of donation
.
Νจ˸
ʘ֑Τdਗ਼࣏ಛ
ږ
ᕘ̊೮͉ࣧᗫၣ१
א
̊
ي
ɪf
I agree to publicize the contribution information
Specified name
and amount
of donation
.
ʔΝจ
Disagree
捐贈者簽名或檢附來文
Donor's Signature or
attach document
ধΝจ˸ɪ࣏ᗍf
I agree tomake the above-mentioned donation.
ϋccccc˜
cccc˚
Year
cc c
Month
ccc
Date
填妥後，請寄至
701
台南市大學路
1
號雲平大樓東棟
4F
「國立成功大學財務處」收或傳真至
06-2002690
即可。
若有任何疑問，請來電
06-2757575
轉
54507
，我們將竭誠為您服務，謝謝您！
ၣѧj
/
ཥɿ
ڦ
ᇌj
年 月 日
（ ）成大財捐字第 號
