Your donation can save a life

Pledge Form

I would like to donate for the needy in following accounts:.

• Clinical Consultation
• Treatment & Medicines
• Sugical Operations
• General
• Diagnosis & pathology
• Hospitalization

I wish to Donate a sum of Rs:

Mode of Payment:

• Cheque
• Pay Order
• Draft
• Cash

Type of Donation::

• Zakat
• Not Zakat

Date:

Name:

Address:

Email:

Phone:

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