Name and Address to be mentioned in the receipt
Donor Name (required)

House Name

Street

City (required)

State

Country

Pin

Amount in figure Rs:

Amount In words Rs:

Purpose

Date ( YYYY-MM-DD)

Mode of Payment

Chq/DD No.

Chq/DD Date

Bank Name

Land Phone

Mobile

Personal Email(required)

Official Email (required)

Note:

Cheque/DD
If you wish to do the contribution by chq/DD please print this form and send along with the Chq/DD to the following postal address


Institute of Applied Dermatology
#MP XVI/575(A) IAD junction,
Uliyathadka, Madhur Road, Kasaragod 671124
Phone : 04994-240862, 240863,
Email : iadorg@gmail.com
Web : www.iad.org.in


Bank transfer
Thank you for contributing to IAD. Once the amount credited in our bank account we will send the receipt. Please mention your name pay in slip

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