Form for payment through Credit Cards
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 P O Box No : 5411 New Delhi 110011 or
Fax this slip to FAX no 91-44-8202221.