Bhakal Request

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Birth Name

Birth Date

[mm/dd/yyyy]

Birth Place

Puja Date

[mm/dd/yyyy]

Temple

Offerings:

Name	Price(US $)	Quantity

Puja Service Fee (includes: holy water, acheta, abir, flower, wick lamp)	(US $)	5.00
Dakshina (Optional)	(US $)
Total Price	(US $)