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Sponsoring Prostheses

Yes, I would like to sponsor the following prostheses for a cancer patient.

Please have a representative contact me.

 
Magic Slate(s) @Rs. 60 (US $ 5)
Breast Prostheses @Rs. 350 (US $ 15)
Jaw Stretcher @Rs. 400 (US $ 15)
POP Protective Prostheses @Rs. 600 (US $ 20)
Maxillar Protective Prostheses @Rs. 1000 (US $ 35)
Dental Protective Prostheses @Rs. 1800 (US $ 60)
Orfit Protective Prostheses @Rs. 3000 (US $ 100)
Larynx Prostheses @Rs. 12,000 (US $ 400)
Limb Replacements @Rs. 24,000 (US $ 800)
Gotex Net Prostheses @Rs. 57,000 (US $ 1900)
Knee Replacements @Rs. 3,80,000 (US $ 13,000)

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: