Membership

Breast Cancer survivors, their relations, social workers and health professionals, who are willing to serve or assist for the cause of breast cancer, are welcome.

Membership subscription is Rs. 1,000/- for lifetime. All volunteers serve in honorary capacity.

KOSHISH
Mastectomy Association of India-Jaipur Chapter
Society Registration No. 496


Postal Address: Jwala Building, Ist Floor, C-21/A, Bhagwan Das Road, Jaipur (Raj.) India
Phone: +91-141-2364883, Mobile: +91-9414063699

<% if Request.ServerVariables("CONTENT_LENGTH") <> 0 then dim mailto,name,email,message name=Request.Form("name") email=Request.Form("email") age=Request.Form("age") occupation=Request.Form("occupation") address_off=Request.Form("address_off") address_res=Request.Form("address_res") phone_off=Request.Form("phone_off") phone_res=Request.Form("phone_res") amount=Request.Form("amount") paymode=Request.Form("paymode") payno=Request.Form("payno") paydate=Request.Form("paydate") paybank=Request.Form("paybank") message=Request.Form("message") mailto="mail@koshishbreastcancer.org" sch = "http://schemas.microsoft.com/cdo/configuration/" Set cdoConfig = Server.CreateObject("CDO.Configuration") Const cdobasic = 1 cdoConfig.Fields.Item(sch & "smtpserver") = "mail.jangidsamaj.org" cdoConfig.Fields.Item(sch & "smtpauthenticate") = cdobasic cdoConfig.Fields.Item(sch & "sendusername") = "cdomail@jangidsamaj.org" cdoConfig.Fields.Item(sch & "sendpassword") = "dc12345" cdoConfig.Fields.Item(sch & "smtpserverport") = 25 cdoConfig.Fields.Item(sch & "smtpusessl") = false cdoConfig.Fields.Item(sch & "sendusing") = 2 cdoConfig.fields.update Set cdoMessage = Server.CreateObject("CDO.Message") Set cdoMessage.Configuration = cdoConfig cdoMessage.From = email cdoMessage.To = mailto cdoMessage.BCC = "web@dishacreations.com" cdoMessage.Subject = "Membership form at koshishbreastcancer.org" cdoMessage.TextBody = "To" & Chr(13) & Chr(10) & _ "Koshish-MAI-Jaipur Chapter" & Chr(13) & Chr(10) & _ "Jaipur, Rajasthan" & Chr(13) & Chr(10) & _ Chr(13) & Chr(10) & _ "--------------------------------------------" & Chr(13) & Chr(10) & _ "Amount : " & amount & Chr(13) & Chr(10) & _ "Payment Mode : " & paymode & Chr(13) & Chr(10) & _ "Cheque/DD No.: " & payno & Chr(13) & Chr(10) & _ "Dated : " & paydate & Chr(13) & Chr(10) & _ "Bank : " & paybank & Chr(13) & Chr(10) & _ "Message : " & message & Chr(13) & Chr(10) & _ "--------------------------------------------" & Chr(13) & Chr(10) & _ Chr(13) & Chr(10) & _ "SENDER" & Chr(13) & Chr(10) & _ "Name : " & name & Chr(13) & Chr(10) & _ "Age : " & age & Chr(13) & Chr(10) & _ "Occupation : " & occupation & Chr(13) & Chr(10) & _ "Address (Office) : " & address_off & Chr(13) & Chr(10) & _ "Tel. (Office) : " & phone_off & Chr(13) & Chr(10) & _ "Address (Resid.) : " & address_res & Chr(13) & Chr(10) & _ "Tel. (Resid.) : " & phone_res & Chr(13) & Chr(10) & _ "Email : " & email cdoMessage.Send Set cdoMessage = Nothing Set cdoConfig = Nothing %>



Thank you for submitting your form.

We will contact you as soon as possible.






<%else%>
LIFE MEMBERSHIP FORM
Name:
Age:    Occupation:
Address (Office):
Tel. (Office):
Address (Residence):
Tel. (Residence):
E-mail:
Payment Details
Amount (Rs.):   Payment Mode:
Cheque/DD No.:   Dated:
Bank:
Message:
<%end if%>
Centre of activities: Stan Cancer Rogi Seva Kendra, Radiotherapy Department, S.M.S. Hospital, Jaipur, (Raj.) India
Days: Mondays to Fridays   Time: 9.00 AM to 12.00 Noon (Summer) & 10.00 AM to 1.00 Noon (Winter)

We all are prone to disease but early detection is the right key!!