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Donation Form

Please fill out this form, print and forward to:

SANJEEVANI
C – 67, Palasapalli, BDA Colony, Aerodrome Area
Bhubaneswar – 20, Orissa, India.
Phone No: 0674 – 2591528 / 094370 33341 (Mob.)
Email ID: sanjeeevanee@yahoo.com / sanjeeevanee1@rediffmail.com


	Name:

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I enclose cheque/postal order for Rs._______________________________________ Please make cheques/postal orders payable to Sanjeevani , Orissa* If you would like to receive an acknowledgement of your donation, please tick here Signature:

Signature: __________________________________________ Date: ____________________________________________

Many Thanks for your Support