|
Name___________________________________________________ |
|
Area Code/Phone _________________________________________ |
|
Address _________________________________________________ |
|
_________________________________________________________ |
|
E-mail ___________________________________________________ |
| write check payable to Jain Center of
Southern California (ref. Hemophilia) |
| Mail check &
form to: |
Dr. Manibhai Mehta
11403 Tortuga Street
Cypress, CA 90630 USA
Tel: (714) 898-3156
Fax: (714) 893-0055
E-mail: manilalmehta@msn.com |
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Thank you for your generous support
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