Donor Registration Form

Registration Form for donations made by Cheque/DD/Pay Order or Credit/Debit Card

Please fill in the form below to send in your donation.
Fields marked * are mandatory.

Your Name

Organization Name

Address

Phone

Mobile

Fax

e-mail

Please accept my donation of

Rs.

Purpose of Donation

Permanent Account Number (PAN)
(mandatory for donation above Rs. 50,000)

Mode of Payment:

	Cheque / Pay Order / DD - To be sent by courier/post to INDIAN CANCER SOCIETY 74, Jerbai Wadia Road, Parel, Mumbai - 400012. Tel: 91-22-24139445 / 24125238 email: info@indiancancersociety.org
	Payment via Credit / Debit Card 2.5% deduction will be made for bank/credit card company charges

Please note that online donations at present can not be accepted from foreign nationals/organisations. Likewise, credit/debit cards issued outside India are not accepted for online donations.

I have read the Terms and Conditions and hereby agree to the same.

Donations made by HDFC Bank Customers

HDFC Bank customers can donate on-line using their NetBanking account by clicking here