About Yourself

 Mr  Ms   Mrs

First Name: ______________________________________________________________________________________

Last Name: ______________________________________________________________________________________

Address: ________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

City: _____________________________________________ State:  ________________________________________

Pin: _________________________

Phone Number(Home): __________________________________ Office : ____________________________________

Mobile: ________________________________________

Email Address: ___________________________________________________________________________________

PAYMENT INFORMATION

Payment Amount: Rs___________________________

Credit Card:
 VISA
 MasterCard

Credit Card #: ______________________________ Exp. Date: ____________

 Cheque (enclosed)

 Cash (do not send cash by mail)

Print Name (as appears on card): __________________________________________________

Signature: ________________________________

WHERE TO GIVE    
I would like my gift/donation to support the following area(s) (please indicate amounts if you are supporting more than one area):

Rs. _______________ Faculty/School/Department of: ________________________________________

Rs. _______________ University Fund

Rs. _______________ Scholarships

Rs. _______________ Student Development Fund

Rs. _______________ Other (please specify): ______________________________________________

ACKNOWLEDGEMENT:

Please acknowledge this gift/donation from myself and:
_____________________________________________________________________________

Relationship (spouse, partner, parent, child, etc):
_____________________________________________________________________________

CONFIRMATION

Signature: _______________________________________________

Date:        ________________________