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| DESIRE Credit Card Payment Form |
| Credit
Card Payment Form for VISA and MASTER card |
Please
fill in the form and print it before mailing to the
given address
below |
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Name |
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Address |
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City |
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State |
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Zip/Pin
Code |
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Phone |
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E
mail |
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| Yes!
I would like to donate towards DESIRE Society an amount of |
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Rs |
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Credit
Card Type |
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Date
of Expiry |
DD
M
Y
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Credit
Card No |
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| Date of birth |
DD
M
Y
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Place |
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Date |
DD
M
Y
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| Please
credit the said amount to "DESIRE Society " |
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| Signature:
_____________________________ |
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Please
mail the form to the address below: |
…………………………cut here to use below
text as address label………………………… |
DESIRE Society
H No: 5-76/28/4
Balaji Nagar
IDA Bollaram Village
Jinnaram Mandal, Medak Dt
Andhra Pradesh-502325, INDIA.
Phone : +91-40-55562844
Email : desiresociety@desireindia.org
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