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Breast Prosthesis Order Form

 
Yes, I would like to order
Breast Prostheses:(size 36 and under) @ Rs. 300 (US $12)
Breast Prostheses:(size 38 and above)@ Rs. 350 (US $14)

Name:
Title (if any):
Organisation (if any):
Address:
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PAYMENT METHOD
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Demand Draft (DD)
Cheque
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Please send Stamped receipt for the donation to:
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