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Title |
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Surname |
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Name/Number |
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Street |
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Area |
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Town/City |
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Email |
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Telephone |
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EITHER Enter total amount pleged: |
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Stage 1 |
Stage 2 |
Stage 3 |
Stage 4 |
2000 miles (est.) Brighton - Istanbul |
2000 miles (est.) Istanbul - Tehran |
1500 miles (est.) Tehran - Karachi |
1000 miles (est.) Karachi-Bhopal |
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Amount Stage 1: |
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Amount Stage 2: |
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Amount Stage 3: |
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Amount Stage 4: |
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- Either print this page and post to:
Lifecycle Bhopal Medical Appeal,
c/o 40 Tewkesbury Road,
Long Eaton,
Nottingham, NG10 1PP
England
- Or Fax it to:
+44 (0)8700 522362
- Or email it directly to sponsor@kodex.co.uk
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