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Please fill out the form below to make an online credit card donation to the Tata Medical Center. Fields with an asterisk (*) are required in order to process your transaction. If you wish to pay by cheque, please complete our Mail-In Donation form and mail it in along with your cheque made payable to the Tata Medical Center.
 
This gift is from...
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Individual  
Corporation  
   
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if "Individual"
*Title :  
Mr.
Ms.
Mrs.
Miss.
Dr.
*First Name:  
Middle Initial:  
*Last Name  
Suffix:              
If salaried name of company:              
Where did you hear about us:              
*PAN:                
 
if "Corporation"
*Corporation:  
Contact Name:  
(If we have a question regarding this donation.)
*E-mail Address:  
*Daytime Phone Number:  
(For immediate e-mail confirmation, please enter your e-mail address above.)
*is this address:  
Home
Business
*Address1:  
Address2:  
*City:           
*Postal Code:  
*Amount:  
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Note : We as a merchant shall be under no liability whatsoever in respect of any loss or damage arising directly of indirectly out of the decline of authorization for any Transaction, on Account of the Cardholder having exceeded the preset limit mutually agreed by us with our acquiring bank from time to time.
Privacy Policy :
The donor information collected is confidential and is not shared with any third party.
 
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