Information about the Deceased: (Name, Year of Birth, Year of Death, Qur'an Sura Number to be recited.*
	Information about the person who is donating the Parcel:
First name:	*
Last name:	*
Address:	*
City:	*
State:
Zip/Postal Code:
Country:	*
Evening phone (with area code):
Day phone (with area code):
Fax:
Email address:

Number of Parcels : X $100 =   US$ ____________ Total Other Donation $ Please print this form, mail it with your check or money order (US$ made payable to HADI) to: Human Assistance and Development International Attention: Memorial Park Department P. O. Box 4598 - Culver City, CA 90231-4598 - USA You can also pay by Credit Card if you Fax us this form with the following Credit Card information : (Fax # : 310-937-9846) Credit Card Name(Visa, Master Card, ect..): _____________ Nbr : ________________________ Expiration Date : ____________   Comments / Special Instructions:   Press the above "Submit" Button so we can reserve a Parcel for you. May Allah (swt) reward you for your kindness and support.  JazakAllah Khairun.

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