PLEDGE FORM
Name
Nationality
Address
State
Country
Zip/Pin Code
Telephone No
Fax No
E-mail Address
Amount of Donation
MAKE CHECKS PAYABLE TO INDUS MEDICAL FOUNDATION
Indus Medical Foundation
Indus Drive, Mount Jakhoo
Shimla- 171 002, India
Mode of Donation
Demand Draft
Cheque
Money Order
Draft No
Date :
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