Name                                         :  
 
Address1                                 : 
 
Address2                                  :
 
Phone No                                 : 
 
Mobile                                       : 
 
E-Mail                                         :
 
Mode of payment               
 

Please draw cheque (only on any bank at Kolkata) OR demand draft  (payable at Kolkata) in favour of “ENDOMETRIOSIS SOCIETY,INDIA”

 
Amount Paid: Rs.                   :
 
(In words)                                :  only
 
Cheque / Draft Number        : Date of Issue:
 
Name of Bank and branch  :
 
Date                                          :

 
 
     
     

 

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