Personal Information of the Donor

Name: ..............................................................................................................

Age:........................ Sex: Male Female

Designation.....................................................................................................

Postal Address...............................................................................................

............................................................................................................................

............................................................................................................................

City..................................................Pin............................................................

State.................................................Country..................................................

Phone..................................................Fax......................................................

E-mail................................................................................................................

Amount.............................................................................................................

(in words.........................................................................................................)

Cheque/DD No.................................................Dated...................................

Drawn on.........................................................................................................

Signature.............................................................Date....................................

The amount should be sent by Cheque/Demand Draft favouring "GENOME FOUNDATION", payable at Hyderabad