Name
Phone Number
Cell Phone Number
Address
City
Zipcode
This is my
Amount
Rs.5,000 Rs.10,000
Rs.15,000 Rs. 20,000
Rs. 25,000 Rs.30,000
Other
Other
Please charge my 
Account Number
Routing Number
Credit Card Number
Expiration Date /
Please charge every
Signature Yes, I authorize the payment.

 

_________________________

Date: ____________________


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