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Bone Marrow Transplant Assistance Form

Yes, I would like to help a leukemia patient undergoing a Bone Marrow Transplant. I understand that this is an extremely expensive procedure and so donations are accepted only in multiples of Rs. 1 lakh ($3000). I further understand that all donations made to CPAA are exempt from Income Tax under Section 80-G of the Income Tax Act (50% tax exemption).

 

Name:
Title (if any):
Organisation (if any):
Address:
City:
Pincode:
Tel No.:
Fax No.:
E-mail
PAYMENT METHOD
Check the method of payment that you are using
Demand Draft (DD)
Cheque
DD / Cheque Number:
Date:
Issuing Bank:

Please send Stamped receipt for the donation to
Address:
Any Other Comments: