Each centre

Rs. 25,000/-

One month

Rs. 10,000/-

Three month

Rs. 30,000/-

Six month

Rs. 60,000/-

One year

Rs. 1,20,000/-

Each programme

Rs. 7,000/-

Yes! I want to Support Change factor

Name of the Programme…………………...................………………………

Period of Support……………………………………………………………….

Please find enclosed my cheque in favour of Change factor

Cheque no. ................................        Amount:.....................

Bank Name: ............................          Branch:......................

Signature:........................

Your Detail: (for Sending you a receipt)

Name: Dr/Mr/Mrs/Ms........................................................................................

Address: ...........................................................................................................
................................................. State: .............................. Country

Pin code:...........................

Phone: ..............................................Mobile:......................................................

Change factor does not ask for or accept cash donations.
Post this form along with cheque to us at:

Ms Nabanita Bhattacharyya,
Secretary,
Change factor
53/9, Priya Nath Middya Road, P.O. Belghoria,  Kolkata 700 056
West Bengal, India