Name _______________________

( As it appears on the credit card)

Address ______________________

PIN ________________ Country ___________________

Phone ______________ (Off)__________________(Res)

Card Diners / MasterCard / VISA / AMEX

Card No. : - - - - - - - - - - - - - - - -

Expiry Date : - - / - - - -

MM YYYY

Amount Rs -- US$-- Euro-- GBP-- ..........................

Currency Amount

Amount in Words : ____________________

Date of Birth : - - - - - - - -
of Card Holder DD MM YYYY

Email Address : __________________

Please make this donation to the Prime Minister's National Relief Fund. I will at no stage dispute this donation and I confirm that this Credit Card belongs to me.

__________________

Signature

(As it appears on credit card).

Card holders either mail this slip to the PMNRF, Prime Minister's Office, New Delhi 110011 or Fax this slip to FAX nos. 91-11-23016857, 91-11-23019545, 91-44-28525769.

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Form for payment through Cheques & Drafts

Cheque /Draft No : ____________________

Bank Name : ____________Branch :_________

Amount : _________ Amount in Words : _____________________

Kindly mail your Cheques / Drafts along with this slip to the PMNRF,
Prime Minister's Office, New Delhi 110011.

All donations are 100% exempt under Indian Income Tax Act

Receipt for donations received shall be sent by Post..