|
|
| Note: *
indicates mandatory |
| Section 1.Please Enter your Information |
|
First
Name:
|
* |
|
Last
Name:
|
* |
|
Address1:
|
* |
|
Address2:
|
|
|
City:
|
* |
|
State
or Province:
|
* |
|
Zip
or Postal Code:
|
* |
|
Country:
|
* |
|
Evening
Phone:
|
* |
|
Day
Phone:
|
|
|
Email
ID:
|
* |
| Section 2. Enter Your Contribution (if any): |
| A.
Enter your Contribution amount for Sai Chintan: |
USD
|
| B.
Enter your Contribution amount for Annadan Seva: |
USD
|
| C.
Enter your Contribution amount for Other Seva: |
USD
|
| D.
Enter your Total Contribution amount: |
USD
|
| You May contribute securely Online or By Check |
| To contribute online fill in the following details: |
| A.
Please Check Card Type |
Visa
MasterCard
Discover
American Express |
| B.
Credit Card Number: |
|
C.
Credit Card Expiration Date: (mm/dd/yy) or
(mm/yy) format only, |
|
| D.
Credit Card Holder Name: |
|
| Write
your comments if any: |
|
|
Section
3. Signature:
|
|
| Signature:
* |
Signature
Date(mm/dd/yy format):
* |
| |
|
| If
contributing by check, mail completed form and check to Shirdi Sai Baba
Sanstha, 12N950 IL Route 47 Hampshire, IL 60140, USA.
|
| All
Donations if made in USA are tax deductable under IRS Section 501(c)(3).
Tax ID 36-4400449. Please consult your tax advisor for details and your
eligibility. |
|
|
|
|
Note:
If you face any technical problems while submitting this form.
Contact Us |
