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Rebuilding Education in Haiti - Solidarity Contribution Form

Support the reconstruction of education in Haiti by making a solidarity contribution. Fill in your details and choose your donation amount.

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Rebuilding Education in Haiti - Solidarity Contribution Form

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  1. Mandato Solidario Reconstruyendo educación en Haití NOMBRES:______________________________________________________________________________________ APELLIDOS:_____________________________________________________________________________________ RUT: ______________________________________TELÉFONO CELULAR:_________________________________ FECHA DE NACIMIENTO___________________________________________________________________________ EMPRESA:_______________________________________________________________________________________ CARGO :_________________________________________________________________________________________ EMAIL: __________________________________________________________________________________________ TU APORTE SOLIDARIO: $1.000____ $2.000____ $3.000____ $4.000____ $5.000____ OTRO APORTE FECHA:_____/_____/______ __________________________________________ FIRMA Autorizo a mi empresa que descuente mensual de mi planilla de remuneraciones el monto indicado en este formulario, solo por un mes. NOMBRE RESPONSABLE AMÉRICA SOLIDARIA_____________________________________________ __________ $ Folio:

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