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Please copy the following onto a word document, complete the information, and email it to us at
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, with the subject "5000 Campaign".
The NIRMAN 5000 Endowment Campaign : Gift Form
Name
Address (for receiving contributors’ packet)
Phone
Email
How did you hear about this campaign?
Why do you want to join it?
Name of referee or Flag Bearer
Name and message published on website Yes/No
Message for website (if 'Yes' ticked above)
Do you wish to become a Flag Bearer? Yes/No
We will send you a yearly newsletter. Would you like to receive more information? Yes/No
(If yes, we will email you with options)
Payment method cash / cheque / money order / bank draft / credit card
Cash: Deposit Rs. 5000 in person at the NIRMAN office. (please do not send cash by post)
Cheque/bank draft: Crossed cheque or draft in the name of “Vidyashram Trust” to the address below (by registered mail, please)
Address for cheques, m.o., and d.d.s (No cash! And please send by registered post!):
NIRMAN
N-1/70 Nagwa
Varanasi-221005
UP, India
Phone: (91) (542) 2366370, (91) (542) 2369527
Click on the following link to use a quick currency converter for the current conversion of Rs. 5000 to USD (converter will pop up in a separate window).
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