INDus Hospital Pledge Form

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

Indus Medical Foundation
4032 Pontiac Trail , Orchard Lake
Michigan, 48323, USA

Mode of Donation

Draft No

Date :

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