Name of Donor :
________________________________________________________________
Resi Address : _________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Tel. : _________________ Fax
: ________________ Email :
__________________________
Organisation : __________________________________________________________________
Designation : ___________________________________________________________________
Off. Address : __________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Tel. : _________________________________ Fax
: _______________________________
Email : ________________________________
Website :
____________________________
We wish to donate Rs. _______________ / (US $. ____________)
to Priyadarshni Academy .
Enrol as a Patron / Co-ordinator (A Category) /
Co-ordinator (B Category).
My Credit Card details are given below :
Bank Name : ________________________________________
Kindly send future communications to my residence
/ office address given above.
________________
Signature
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