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First Name*:
Last Name*:
Organization*:
Adrress Line 1:
Adrress Line 2:
Adrress Line 3:
Date of Birth:
City*:
Zip / Pin Code*:
E-mail Id*:
Work Phone:
Mobile / Home Phone:
Donation Amount*:
United States Dollar	Indian Rupees
Donor Remarks:

I want to adopt poor-meritorious student / students for education under Pratibha Poshak project.
I want to support Vidya Poshak to run its various student related activities and operating expenses.
To support library (cost of books).

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I agree for terms and conditions of Vidya Poshak

1) On submitting the form you will be forwarded to the third party Payment Gateway for final confirmation of the actual payment. 2) 10% of the donation amount will be utilized towards administration by Vidya Poshak and Payment Gateway service charges.